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i^eference  Ititirarp 


Presented  oy 

I^DR.  WILLIAM  J.  OIES/^ 

?o  enrich  the  library  resources 

available  to  holders 

of  the 

GIES  FELLOWSHIP 

in  Biological  Chemistry 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
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PRACTICAL 

ORAL  HYGIENE, 
PROPHYLAXIS 


AND 


PYORRHEA  ALVEOLARIS 


BY 

ROBIN  ADAIR,  B.  S.,  M.  D.,  D.  D.  S. 

Professor  or  Oral  Prophylaxis  and  Pyorrhea  Alveolaris,  Southern 

Dental  College,  Atlanta,  Ga.;  Oral  Surgeon,  Grady  Hospital 

(1910-1912);  Member  Fulton  County  Medical  Society, 

Georgia  State  Medical  Society,  Georgia  State 

Dental  Society,  National  Dental 

Society. 


1914 

Byrd  Printing  Company 

Atlanta,  Ga. 


Copyright  1914  by 
ROBIN  ADAIR 

at  the  Library  of  Congress,  Washington,  D.  C. 


All  rights  reserved,  including  those  of  translation  into  foreign  languages. 


TO 
HIS     FATHER 

who  for  forty-five  years  of  active  practice 

has  advocated  the  principles  of  Oral  Hygiene 

and  whose  highest  aspirations  have  been 

for  his  son  to  further  the  cause 

THIS  WORK 

is  lovingly  dedicated  by 

THE  AUTHOR 


PREFACE. 

This  book  is  \yi'itten  for  those  dentists  who  desire 
practical  information  on  the  subjects  of  oral  hygiene, 
prophylaxis,  and  pyorrhea  alveolaris. 

The  hrst  section  is  devoted  to  the  great  forward 
movement  of  oral  hygiene.  Here  are  given  methods  and 
forms  for  dental  inspection  of  school  children,  and  a  col- 
lection of  carefully  selected  lectures  furnishing  the  proper 
material  for  those  called  upon  to  deliver  popular  talks 
before  school  children  and  women's  clubs.  The  author 
has  found  that  diagramatic  pictures  often  prove  the  most 
convincing  way  to  teach  the  facts  of  oral  hygiene  to  a 
patient.  This  section  contains  illustrations  which  may 
be  shown  and  explained  to  a  patient  while  in  the  dental 
chair. 

The  second  section  contains  practical  information  con- 
cerning the  most  ethcient  methods  to  conduct  prophylaxis 
in  a  dental  practice,  and  names  the  materials  to  use  for 
such  work.  The  training  of  female  assistants  and  the 
dental  nurse  question  are  treated  in  a  most  practical 
manner. 

The  third  section  is  a  comprehensive  description  of 
pyorrhea  alveolaris.  Here  is  described  in  detail  the 
methods  of  treatment  now  prominent  before  the  dental 
profession.  The  business  phase  of  the  question,  so  sel- 
dom mentioned  in  discussion  or  literature,  is  presented 
in  a  frank  manner.  The  medical  profession  is  now 
greatly  interested  in  the  question  of  ''oral  sepsis."  To 
meet  this  advance,  the  author  devotes  a  chapter  to  their 
interests. 

I  have  frequently  been  asked  (juestions  on  the  above 
subjects.  The  articles  I  have  written  for  dental  journals 
have  elicited  numerous  requests  for  further  information, 
and  I  have  become  convinced  that  there  is  need  of  a  book 
dealing  with  such  matters  in  a  thoroughly  practical 
manner. 


VI  Peeface. 

I  have  endeavored  to  familiarize  myself  with  the 
methods  of  other  specialists  in  this  line  of  work,  and, 
from  time  to  time,  have  visited  them  in  their  offices  in 
order  to  inspect  their  work,  and  discuss  with  them  the 
methods  used.  A  number  of  these  men  have  been  quoted, 
and,  in  some  instances,  they  have  prepared  descriptions 
of  certain  parts  of  their  work  for  publication  in  this  book. 

I  am  fully  aware  that  I  have  not  always  observed  the 
proper  literary  obligations;  for  my  accumulation  of 
material  collected  for  dental  college  lectures,  with  no  idea 
of  future  publication,  has  come  from  a  store  of  thoughts 
of  many  writers  in  common. 

''What  he  thought  he  might  require. 
He  went  and  took." 

All  sources  of  information  on  these  special  subjects 
have  been  freely  drawn  on,  and  wherever  possible,  credit 
has  been  given  for  any  matter  used. 
Atlanta,  Geoegia, 
February  1,  1914. 


MT  LITERARY  OBLIGATION. 


Below  I  give  the  names  of  those  dentists  and  physicians  who  have 
written  contributions  especially  for  this  work;  and  a  partial  list  of  those 
whose  methods  and  writings  haA^e  been  quoted: 


Adair,  E.  B. 
Black,  G.  V. 
Black,  Arthur. 
Carmichial,  J.  P. 
Beetman,  M.  M. 
Belcher,  W.  W. 
Corley,  J.  P. 
Clapp,  G.  W. 
Deichmiller,  Conrad. 
Dunlop,  W.  F. 
Ebersole,  W.   G. 
Fones,  A.  C. 
Fisher,   Prof. 
Fletcher,  M.  H. 
Goble,  L.  S. 
Gearhart,  C.  M. 
Good,  Eobt. 
Greenfield,  E.  J. 
Hunter,  Wm. 
Harris,  G.  B, 
Howard,  C.  C. 
Hoff,  N.  S. 
Head,  Jos. 
Hunt,  G.  E. 
Hay  den,  Gillette. 
Howes,  Minnie. 
Harrell,  H.  B. 
Hyatt,  T.  P. 
Hart,  C.  E. 
Hutchinson,    R.   J.,   Jr. 


Hartzell,  T.  B. 
Jenkins,  N.  S. 
Jungman,  J.  W. 
James,  A.  P. 
Kelley,  H.  A. 
Kells,  C.  Edmund. 
Kirk,  E.  C. 
Lundy,  E.  A. 
Merritt,  A.  H. 
MeCall,  J.  O. 
MacKee,  Geo.  M. 
Marshall,  J.  S. 
Niles,  G.  M. 
Nodine,  A.  M. 
Patterson,  J.  D. 
Peek,  A.  E. 
Pickerill,  H.  F. 
Pierce,  C.  N. 
ELein,  M.  L, 
Solbrig,  S.  O. 
Stevenson,  A.  H. 
Smith,  D.  D. 
Sarrazin,  J.  J. 
Spalding,  E.  B. 
Skinner,   F.   H. 
Talbot,  E.  S. 
Visanska,   S.   A. 
Younger,  J.   W. 
Zarbaugh,  L.  L. 


I  also  acknowledge  obligation  to  the  following:  The  Dental  Sum- 
mary, Dental  Dispensary  Record,  Oral  Hygiene,  S.  S.  White  Dental 
Mfg.  Co.,  The  Cleveland  Dental  Mfg.  Co,  and  J.  W.  Ivory. 


THE  AUTHOR. 


319  Grant  Bldg.,  Atlanta,   Ga. 


CONTENTS 

PART  I. 

PRACTICAL  ORAL  HYGIENE 

Page 
CHAPTEE  I. 

/  Oral  Hygiene  Movement. 

\       Progress  Made  and  Prediction  for  the  Future. — In  Literary  Colleges. — 


Personal  Oral  Hygiene  for  Dentists. 


CHAPTEE  II. 

Oral  Hygiene  from  Infancy. 
Some  Fundamental  Observations. — Sixth  Year  Molars. — Mastication  of 

Food.— The  Neglected  Mouth 12 

CHAPTER  III. 

Popular  Lectures  on  Dental  Subjects. 
Teeth  and  Their  Care. — Dental  Summary.     Outline  Lectures,   (1)   For 
Mothers'   Clubs.      (2)    To   Children.      (3)    For  Nurses   and   Physi- 
cians.     (4)    To  Kindergarten. — By  Stevenson 20 

CHAPTEE  IV. 

Popular  Lectures — Continued. 
An  Illustrated  Lecture. — Zarbaugh.     Lecture  for  School  Children  from 
Fourth  to  Eighth  Grades. — Corley.     Lecture  for  School  Children. — 
Hunt     44 

CHAPTEE  V. 

Dental  Examination  and  Clinic  for  Public  Schools. 
History. — Object   of   School  Inspection. — How  to   Start  School   Inspec- 
tion.— Argument  for  Free  Dental  Clinic  and  School  Inspection.  ...      6S 


X  CO^STTENTS. 

CHAPTEE  VI.  Pagk 

Forms  Used  in  Dental  Inspection  and  Clinics  foe  Public  Schools. 
Instructions  for  Making  School  Examinations. — Dispensary. — The  For- 
syth Dental  Infirmary 78 

CHAPTER  VII. 
Tuberculosis  and  the  Oral  Hygiene  Mo\^ment 91 

CHAPTER   VIII. 

Brushing  the  Teeth. 
Shape  of  Brush. — Teaching  the  Technique  of  Brushing. — The  Direction 

Card.— "The   Bad   Breath   Signal" 96 

CHAPTER  IX. 

Cleaning  the  Teeth. 
Skill  Required  for  the  Work. — The  Best  Time  to  Clean  the  Patient's 
Teeth.- — The  Use  of  a  Disclosing  Solution. — Instruments  Used  for 
Cleaning   the   Teeth. — Abrasive  Mixtures  to   be  Used   in   Cleaning 
the  Teeth 110 


PART  II. 
PRACTICAL  ORAL  PROPHYLAXIS 

CHAPTER  X. 

Prophylaxis. 
Definition  and  Views  of  Smith,  Spalding,  Fletcher,  Fones,  Taylor,  Rhein 

and  Harper 121 

CHAPTER  XI. 

Why  is  Prophylaxis  Necessary? 
Where    to   Begin    Prophylaxis. — Frequency    of    Treatment. — Object    of 

Prophylaxis   130 

CHAPTER  XII. 

The  Prophylaxis  Class. 
Preliminary  Work  Before  Entering  on  Prophylaxi.s'. — Prophylaxis  Tech- 
nique.— Views  of  Kelley,  Howes  and  Goble 140 


Contents.  xi 

CHAPTEE  XIII.  Page 

Instruments  and  Polishing  Material  Useful  in  Prophylaxis  ....   149 

CHAPTEE   XIV. 

Prophylaxis  Treatment  of  Fissures  and  Groo\t:s. 
Soft   Spots. — Sensitive  Area  Treatment 155 

CHAPTEE  XV. 
Kesults  of  Prophylaxis  Treatment 159 

CHAPTEE  XVI. 

Some  Important  Observations  on  the  Teeth  and  Saliva 162 

CHAPTEE   XVII. 

Methods  of  Notification  Used  by  Kjells,  Fones  and  Adair 16S 

CHAPTEE  XVIII. 
Notification  System  of  lMcCall,  Kelley  and  Hayden 174 

CHAPTEE  XIX. 

Training  of  Female  Assistant. 
"When  Should  Such  Help  be  Installed  in  a  Dental  Office? — The  Best 
Way  to  Secure  Good  Help. — Methods  of  Training. — Telephone  and 
Eeception  Eoom. — Eecords  to  be  Used  by  Female  Assistants. — Of- 
fice Training  for  the  Position  of  Dental  Nurse 184 

CHAPTEE  XX. 

The  Dental  Nurse. 
Vie'n'S   of    Fones,    Merritt,   Hyatt,    Hart,   Ebersole,   Nodine,    Kirk   and 
Skinner. — The  Proposed  Law  of  Massachusetts  as  Endorsed  by  the 
State  Dental  Society 193 

CHAPTEE    XXI. 

Teaching  of  Oral  Hygiene,  Prophylaxis  and  Pyorrhea  in 
Dental  Colleges. 
Practical  Methods'  Employed  by  the  Author. — The  Eesults  Obtained. — 

The  Need  of  Such  Instruction 204 


XII  COXTEXTS. 

PART  III. 

A  PRACTICAL  DESCRIPTION  OF  PYORRHEA  ALVEOLARIS 
AND  ITS  TREATMENT 

CHAPTER  XXII.  Page 

Pyorrhea  Alveolaris. 
Synonyms. — Definition. — Causes. — What  is   Tartar  and  its  Formation? 

— Black's  Theory. — Kind  of  Calculi  and  Deposits 211 

CHAPTER  XXIII. 

Pathology  of  Pyorrhea  Al\^olaris. 
Recession  and  Congestion  of  the  Gums. — The  Changes  in  the  Peridental 
Membrane   and   Alveolar   Process. — Tooth   Root   Absorption. — For- 
mation of  Pus  and  Pockets. — Alveolar  Abscess  in  Pyorrhea 222 

CHAPTER  XXIV. 
Symptom,  Duration,  Diagnosis  op  Pyorrhea 230 

CHAPTER  XXV. 

Prognosis  in  Pyorrhea  Alveolaris. 
Blood  Pressure. — Artificial  Teeth  in  Regard  to  Pyorrhea 236 

CHAPTER  XXVI. 

Instruments  por  Use  in  Prophylaxis  and  Pyorrhea  Work 243 

CHAPTER  XXVII. 
Treatment  and  Instrumentation. 
The   Younger   Method. — Strong  Drugs   Used   and   Objection   to    Their 

Use.— The  Joseph  Head  Method 250 

CHAPTER  XXVIII. 
The  Author's  Method  and  System  op  Treating  Pyorrhea 257 

CHAPTER  XXIX. 

The  Author's  Method  and  System  op  Treating  Pyorrhea — Continued. 
The  Medical  Treatment. — Practical  Hints  for  Application. — An  Unex- 
plained Chemical  Formation  in  the  Mouth 264 


Contents.  xin 

CHAPTER  XXX.  Page 

Treatment — Continued. 
Treatment  of  Merritt,  Patterson,  Sarrazin,  Dunlop, 

Lundy  and  Fletcher 272 

CHAPTER  XXXI. 

TrexVtment — Continued. 
A  Technical  D-escription  of  the  Surgery  of  the  Root  Surface,  and  the 

Instruments  Most  Useful  in  Achieving  It. — ^By  T.  B.  Hartzell 284 

CHAPTER  XXXII. 

Implantation. — Bifuecation    Treatment. — ^Removal   of    Puxps. 
Amputation  of  Tooth  Roots. — Treatment  of  Pyorrhea!  Abscess 290 

CHAPTER  XXXIII. 

Vaccination  Treatment. 
Bridge  Work  and  Splints  for  Pyorrhea.- — The  X-Ray  and  Pyorrhea. — 

By  Geo.  M.  IVIacKee 298 

CHAPTER  XXXrV. 

Sterilization  of  Instruments  and  Preparation  of  the  Mouth  for 

Surgical  Work    309 

CHAPTER  XXXV. 
Business  Side  of  Pyorrhea  Alveolaris 312 

CHAPTER  XXXVI. 

The  Medical  and  Surgical  Aspect  of  Oral  Hygiene  and  Pyorrhea. 
Views   of   Prominent   Medical  Men. — Suggestions   to   Physicians   as   to 
Care   of   the  Mouth   in    Sickness. — Oral   Preparation   for   Surgical 
Work    319 


PART  I. 

PRACTICAL  ORAL  HYGIENE 


CHAPTER     I. 
ORAL  HYGIENE  MOVEMENT. 

PBOGBESS     MADE     AND     PREDICTION     FOR     THE     FUTURE. IN 

LITERARY   COLLEGES.— PERSONAL   ORAL   HYGIENE 
FOR  DENTISTS. 

Only  in  recent  years  have  some  of  the  more  progres- 
sive dentists  begun  to  reahze  their  duty  to  the  public  in 
the  matter  of  educating  them  on  the  importance  of 
prophylactic  and  oral  hygienic  measures  in  the  care  of 
their  teeth,  and  to  teach  them  the  great  results  which  can 
thus  be  secured  in  the  way  of  increased  health,  happi- 
ness, and  freedom  from  disease.  This  propaganda  has 
been  termed  the  Oral  Hygiene 3lovement. 

It  must  be  admitted  that  the  slowness  of  the  dentists 
in  realizing  their  duty  along  this  line  has  been  discourag- 
ing to  those  who  have  had  the  interest  of  the  movement 
at  heart,  but  we  all  know  that  the  dental  profession  is 
a  busy  and  hard  working  profession,  having  strenuous 
requirements  on  its  time  and  resources.  Still  the  timo 
cannot  be  far  distant  when  the  dentists  of  America  will 
realize  their  great  opportunity  as  well  as  their  duty 
along  the  line  of  educating  the  people.  It  will  mean  the 
placing  of  the  propaganda  on  a  higher  plane  of  useful- 
ness and  the  accomplishment  of  results  in  every  way 
equal  to  the  best  work  done  in  recent  years  by  the  medical 
profession  in  the  line  of  preventive  measures. 

It  can  already  be  noticed  that  the  dentists  of  this 
country  who  are  interesting  themselves  in  this  movement 
are  taking  the  places  at  the  head  of  the  profession,  and 
are  reaping  just  rewards  for  their  work  in  furthering 
the  public  welfare. 

It  has  been  stated  that  only  twelve  per  cent,  of  any 
community  pays  any  attention  to  the  teeth,  but,  since 


4  Peactical  Oral  HYGiEisrE. 

we  know  liow  inefficient  most  of  this  care  is,  we  realize 
that  a  very  much  smaller  percentage  practices  oral 
hygiene  in  a  really  efficient  manner. 

It  is  somewhat  a  reflection  on  the  dental  profession 
that  a  layman,  Mr.  Horace  Fletcher,  did  more  in  a  few 
years  to  acquaint  the  people  with  oral  hygiene  facts  than 
did  the  whole  dental  profession  in  its  former  career. 

The  public  is  beginning  to  be  aroused  on  the  subject 
of  oral  hygiene  and  they  read  eagerly  the  magazine  and 
daily  newepaper  articles  on  the  subject.  The  whole 
trouble  to-day  is  that  just  such  trustworthy  (?)  facts  are 
given  them  as  are  to  be  found  in  the  columns,  "Advice 
to  the  Lovelorn,"  and  "How  to  Eemove  Freckles." 

Not  all  dentists  are  in  possession  of  facts  relating  to 
the  general  health  and  welfare,  which  if  properly  pre- 
sented to  the  laity,  would  soon  make  the  advice  of  the 
dentists  as  much  sought  after  as  is  that  of  the  medical 
man.  The  truth  is  that  up  to  the  present  time,  the  laity 
and  the  medical  profession  have  been  ignorant  on  this 
subject,  and  for  the  simple  reason  that  the  dentists  them- 
selves have  not  done  their  duty  in  the  way  of  educational 
propaganda. 

One  reason  for  the  lack  of  knowledge  on  the  part  of 
the  public  is  shown  by  the  following  quotations  taken 
from  a  common  school  physiology: 

' '  The  teeth  are  bony  keys  set  in  the  jaw-bones.  Those 
in  the  front  part  of  the  jaw  are  sharp,  so  as  to  bite  lumps 
of  food.  Those  in  the  back  part  of  the  mouth  are  flat, 
so  as  to  grind  food  to  pieces.  Between  the  ages  of  6  and 
13  the  child  loses  its  first  teeth  and  gets  a  whole  new 
set,  and  8  additional  ones.  Biting  hard  things,  such  as 
nuts  and  wood,  often  breaks  the  enamel  and  causes  the 
teeth  to  decay.  When  the  decay  reaches  the  nerve,  the 
tooth  aches  and  becomes  very  tender." 

These  false  impressions,  gained  at  an  early  age,  are 
very  hard  to  overcome  when  the  children  grow  older. 
We  should  bend  our  energies  to  correct  this  state  of 


Oral  Hygiene  ^Iovemext.  5 

affairs  by  establishing  in  our  schools  a  brief  but  thor- 
oughl}'-  scientific  course  on  these  subjects. 

Not  only  does  the  proper  dental  attention  give  the 
owner  the  means  whereby  he  can  more  comfortably 
masticate  his  food,  but  also  serves  as  a  preventive  against 
those  agents  which  make  against  his  general  physical 
welfare.  The  lack  of  this  attention  not  only  causes  a 
filthy  condition,  which  furnishes  the  bed  where  germs 
can  readily  grow,  but  also  lowers  the  patient's  resistance, 
and  this  results  in  jDhysical  deterioration. 

A  few  years  ago  this  fact  was  not  generally  recog- 
nized, but  to-day  the  army  and  navy,  the  big  factories, 
and  even  the  base  ball  clubs  often  emplo}^  a  good  dentist 
for  the  purpose  of  protecting  their  employees. 

The  match  factories  were  the  first  to  recognize  the 
benefits  of  protecting  their  employees  against  mouth 
infections.  Previous  to  dental  inspection  and  care, 
phosphor-necrosis  was  a  dreaded  and  common  affliction 
among  those  thus  employed.  Since  the  employment  of  a 
regular  dentist,  this  condition  has  been  reduced  to  a 
rarity. 

Morris  and  Co.,  one  of  the  big  stock  yard  firms  of 
Chicago,  have  just  installed  a  fully  equipped  dental 
office  for  the  purpose  of  giving  their  thousands  of  em- 
ployees free  dental  attention.  This  firm  was  convinced 
that  the  health  of  its  workers  would  be  better,  and  that 
a  great  saving  of  time  would  result  from  having  a 
dentist  close  at  hand.  This  special  inducement  to  these 
people  saves  many  teeth  which  would  otherwise  be  lost. 

This  is  in  line  with  the  efforts  of  many  of  the  larger 
corporations  to  guard  against  any  thing  which  would 
incapacitate  the  employees  from  giving  good  service. 
Undoubtedly,  bad  teeth  are  the  greatest  cause  for  loss  of 
time,  and  these  free  clinics  will,  in  time,  l>e  a  regular 
equipment. 

Mam'  of  the  larger  southern  cotton  mills  either  em- 
ploy a  dentist  for  their  employees,  or  make  it  to  his 


6  Peactical  Okal  Hygiene. 

interest  to  locate  in  the  vicinity  by  giving  Mm  free  rent 
or  by  other  means. 

One  mill  in  the  Piedmont  district,  which  owns  the 
township,  selected  a  well  equipped  young  dentist  and 
gave  him  free  rent,  assured  him  the  influence  of  the 
officials  in  his  oral  hygienic  endeavors,  and  guaranteed 
him  freedom  from  competition  by  the  more  or  less  con- 
scienceless dentists  who  often  infest  such  places.  He  is 
free  to  give  these  mill  operatives  much  valuable  advice 
and  treatment,  and  in  turn,  they  furnish  their  employers 
better  work.- 

One  not  familiar  with  the  ignorances  and  prejudices 
existing  among  these  cotton  mill  operatives,  cannot 
imagine  the  difficulties  to  be  met  with  in  trying  to  make 
better  their  conditions.  Not  long  since,  I  was  in  the 
township  mentioned  and  questioned  some  of  these  people 
about  their  teeth.    I  was  congratulating  them  on  having 

such  a  good  dentist  as  Dr. .    One  of  them  said, 

''Dr. may  be  a  very  good  fellow,  but  I  am  not 

going  to  let  him  work  for  me  or  my  family  any  more, 
for,"  said  he,  ''I  had  the  dickens  of  a  toothache  and 
went  up  to  him  to  get  it  pulled  and  he  commenced  some 
rot  about  cleaning  teeth  and  saving  my  tooth.  I  didn't 
have  any  time  for  such  stuff,  and  went  to  Greenville 

and  got  Doc. to  pull  it.    Dr. used  to 

pull  teeth,  but  he  has  got  to  talkin  so  much  about  clean 
mouths  that  he  is  losing  some  of  his  trade." 

"While  the  contemplation  of  such  a  clientele  is  not 
pleasant,  it  emphasizes  more  than  ever  the  need  of  edu- 
cation on  these  subjects. 

If  we  have  any  patients  who  control  mills,  it  is  our 
duty  to  show  them  the  benefits  of  such  service,  and  sug- 
gest some  good  young  dentist  for  the  position. 

To  ''some  good  young  dentist"  the  suggestion  is 
offered  that  he  see  some  mill  official  with  whom  he  is 
acquainted,  and  show  him  the  immense  advantages  to 
be  derived  from  having  the  right  sort  of  dentist  con- 
nected with  the  mill.    The  experience  is  well  worth  while, 


Oral  Hygiene  Movement.  7 

the  good  done  incalculable,  and  the  financial  returns  are 
generally  satisfactory  if  the  co-operation  of  the  officials 
is  secured. 

At  the  present  time  where  wages  are  high  and  hours 
short,  officials  who  control  large  numbers  of  operatives 
are  rapidly  awakening  to  the  advantages  of  measures 
which  will  enable  them  to  secure  more  efficient  services 
from  their  employees.  As  regards  medical  advice  they 
are  always  ready  to  have  lectures  on  sanitation,  and  the 
suggestions  of  the  resident  physician  are  most  readily 
carried  out. 

Marshall,  in  his  ' '  Mouth  Hygiene, ' '  calls  attention  to 
the  fact  that  practically  no  one  escapes  the  diseases  of 
the  mouth,  and  that  dental  decay  is,  without  doubt,  the 
noLOst  common  disease  that  afflicts  the  human  family.  He 
further  states  that  in  his  practice  of  about  forty  years^ 
he  has  not  seen  but  about  four  instances  where  persons 
had  reached  mature  life  without  some  form  of  dental 
decay. 

If  we  could  only  realize  that  the  condition  of  faulty 
mouths  keeps  our  young  men  out  from  even  such  employ- 
ment as  the  Army  and  Navy,  and  that  so  few  are  able 
to  pass  the  simple  requirements,  we  might  wake  up  on 
this  subject.  Even  more  so,  when  considered  that,  had 
the  oral  hygiene  movement  started  back  when  these  appli- 
cants were  children,  they  would  not  be  hampered  in  this 
way.  In  our  Philippine  Army  thirty-five  per  cent,  of  the 
catarrhal  dysentery  is  said  to  be  traceable  to  septic 
mouth  conditions. 

Thousands  of  applicants  for  our  Army  and  Navy  are 
rejected  because  of  faulty  teeth.  Not  only  is  this  true 
in  our  Army,  but  in  England  also,  it  has  been  said  that 
five  hundred  were  rejected  in  one  year  because  of  im- 
proper oral  conditions.  Further  than  this,  a  report 
states  that  twenty-four  per  cent,  of  the  English  Army 
recruits  have  useless  teeth.  At  Anapolis  an  average  of 
only  two  per  cent,  of  the  men  who  apply  for  entrance  pass 
without  first  having  some  dental  work  done. 


8  Pkactical  Oeal  Hygiene. 

Grermany  lias  recognized  that  the  great  efficiency  in: 
her  army  is  maintained  by  attention  to  oral  hygiene. 
The  present  requirement  is  that  each  soldier  shall  brnsh 
his  teeth  at  least  once  a  day,  and;  the  first  sergeant  in. 
each  company  must  see  that  this  order  is  carried  out. 
Many  other  countries  have  taken  steps  along  this  line  in 
regard  to  the  armies.  While  America  will  probably 
never  exercise  this  parental  care,  still  we  are  bordering 
on  this,  for  in  the  Philippine  Army  the  soldiers  are  re- 
quired to  have  monthly  examinations  of  their  mouths  by 
the  Post  Surgeons. 

The  American  Army  and  Navy  employ  the  best  of 
dentists,  who  secure  their  positions,  not  through  any 
politics  or  favoritisms,  but  by  standing  the  hardest  kind 
of  examination.  These  men  not  only  do  repair  work  for 
the  soldiers,  but  they,  working  with  the  medical  author- 
ities, see  that  their  mouths  are  kept  clean.  It  is  a  remark 
able  story  that  the  Surgeon  General  was  willing  to  raise 
the  dental  requirements  for  admission  into  the  Army  and 
Navy,  yet,  when  the  raise  was  attempted,  it  was  found 
that  the  number  of  recruits  was  so  reduced  that  the  old 
standard  had  to  be  again  accepted. 

Undoubtedly,  more  and  better  oral  hygiene  will  be 
taught  and  required  each  year  in  our  Army,  and  the 
officials  in  charge  will  find  that  greater  efficiency,  better 
health,  and  a  better  fighting  force  can  be  maintained  by 
having  the  men  keep  their  mouths  in  a  clean  condition. 

The  prediction  can  be  made  that  the  day  is  not  far 
distant  when  our  department  stores  and  other  business 
houses  where  the  clerks  come  in  contact  with  customers, 
will  provide  either  by  pamphlet,  lecture,  or  by  furnish- 
ing free  prophylaxis,  the  necessary  means  for  insuring 
a  healthy  condition  of  their  employees'  mouths,  and  it 
will  certainly  more  than  repay  them  for  the  time  and 
money  expended.  We  know  that  when  a  clerk  with  un- 
kept  teeth,  shining  crowns,  and  bad  breath  waits  on  us, 
it  makes  a  difference.    It  also  makes  for  a  sale,  if  the' 


Oral  Hygiene  for  Literary  Colleges.  9 

clerk  has  a  pretty  well  kept  mouth.  Here  is  a  fertile 
field  for  the  oral  hygiene  worker;  this  class  of  people 
cannot  pay  for  expert  services.  It  costs  too  mnch  and  the 
loss  of  time  is  also  an  item.  They  are  often  the  victims 
of  dental  parlors  where  their  teeth  are  fitted  with  golden 
trappings  which  shine  ont  as  the  headlights  on  an 
automobile. 

ORAL  HYGIENE  FOR  LITERARY  COLLEGES. 

One  of  the  largest  and  best  military  schools  for  boys  is 
located  some  ten  miles  from  Atlanta.  The  attendance  is 
gathered  from  all  over  the  United  States,  and  many  for- 
eign countries  are  represented.  I  have  had  the  pleasure 
of  having  many  of  thse  boys  for  patients.  Almost  with- 
out exception,  they  have  presented  mouths  needing  much 
attention,  especially  for  oral  sepsis.  I  have  counted  up 
the  time  lost  by  these  boys  going  to  and  from  the  dentist, 
and  the  loss  of  study-time  due  to  pain  which  I  believe 
will  show  far  greater  than  any  other  cause.  The  presi- 
dent realizes  this  condition  and  will  in  time  accept  the 
plans  suggested. 

The  same  condition  prevails  at  our  educational  insti- 
tutions situated  in  all  our  cities.  While  the  dental  in- 
spection of  our  public  schools  is  productive  of  much 
good,  it  is  undeniably  true  that  we  are  neglecting  just 
as  great  a  field  in  the  colleges.  These  institutions  are 
filled  with  young  ladies  and  gentlemen  who  are  to  be  the 
future  parents  and  who  can  be  made  our  earliest  and 
best  missionaries.  At  this  age,  fourteen  to  twenty-two, 
they  are  very  receptive  to  suggestions  on  oral  hygiene. 
Not  only  owing  to  their  ignorance  of  their  mouth  con- 
ditions, but  also  the  great  loss  of  time  for  the  necessary 
dental  attention,  they  delay  until  too  late.  Even  those 
who  endeavor  to  have  their  teeth  looked  after  are  some- 
times recommended  to  the  poor  operators.  I  have  known 
of  several  cases  where  inferior  dentists  have  secured 
some  of  the  teachers  in  a  school  for  patients,  and  have 


10  Peactical  Okal  Hygiene. 

done  their  work  free  of  charge  with  the  understanding 
that  the  teachers  solicit  work  for  them,  among  the  stu- 
dents. In  one  of  these  instances,  the  college  officials  were 
unable  to  overcome  a  teacher's  persuasive  powers  with 
the  students,  and  the  latter  were  led  to  patronize  a  man 
who  was  about  on  a  par  with  those  employed  to  work 
in  dental  parlors.  This  happened  in  a  large  institution. 
How  much  better  it  would  have  been  for  the  president 
to  have  had  on  his  staff,  a  reputable  dentist  to  reside  in 
or  near  the  college,  or  to  have  a  city  dentist  to  come'  to 
the  college  on  regular  days,  and  have  a  well  equipped 
dental  office  in  the  college  building.  Think  of  the  better 
service  and  the  saving  of  time  and  trouble  to  the  teachers 
and  students.  Every  institution  can  afford  a  well 
equipped  hospital,  whereas  the  cost  of  a  dental  office  need 
not  be  nearly  so  much  as  that  of  the  hospital. 

Some  years  ago,  I  accepted  an  invitation  to  deliver  a 
lecture  on  the  subject  of  "Teeth,"  at  one  of  our  larger 
female  colleges.  One  of  the  local  dentists  got  interested, 
worked  up  some  enthusiasm,  arranged  the  date,  secured 
a  lantern,  and  introduced  me.  My  whole  theme  was 
turned  to  what  benefits  they  could  secure  by  a  course  on 
"Oral  Hygiene."  I  made  this  lecture  as  dignified  and 
impressive  as  study  and  slides  could  do.  The  president 
and  the  dentists  followed  up  the  suggestions,  and  now, 
for  several  years,  this  institution  has  been  giving  the 
students  a  regular  and  systematic  course  by  a  professor 
in  oral  hygiene.  There  is  a  possibility  that  spasmodic 
lectures  may  do  some  good,  but  if  the  work  is  carried  out 
in  the  regular  curriculum,  as  in  the  college  just  men- 
tioned, great  good  can  be  accomplished. 

personal  oral  HyGIENE  FOR  DENTISTS. 

If  you  want  to  kill  an  oral  hygiene  movement,  just  let 
a  dentist  with  a  dirty,  filthy  mouth  and  foul  breath  lec- 
ture to  the  parents  or  examine  the  children's  mouths. 
The  President  of  a  Dental  Society,  if  he  has  the  interest 


Peesoxal  Oral  Hygiene  for  Dentists.  11 

of  the  movement  at  heart,  will  select  men  with  mouths  in 
good  condition  to  do  this  work.  To  show  the  inconsis- 
tency of  the  position,  one  of  the  greatest  lecturers  in  this 
work,  carries  around  with  him  a  mouth  that  is  extremely 
foul.  Others,  in  just  as  bad  condition,  are  doing  the 
same  work  all  over  the  country.  Dentists  must  look  after 
their  own  mouths  first,  if  they  desire  their  words  to  have 
any  weight  with  the  people.  One  of  the  greatest  draw- 
backs in  our  work  along  the  line  of  oral  hygiene,  is,  un- 
doubtedly, the  existing  conditions  of  some  dentists' 
mouths.  A  few  years  ago,  I  made  an  examination  of  some 
twenty  dentists'  mouths  which  reflects  the  average  to  be 
found,  anywhere.  The  author  is  so  ashamed  of  the  re- 
sult that  he  declined  to  publish  the  table. 

To  those  dentists  who  think  only  the  patient  needs 
oral  hygiene  training,  let  them  examine  the  mouths  of 
a  few  of  their  brethren  at  any  dental  convention.  The 
editor  of  the  Dental  Dispensary  Record  has  well  said 
''that  the  weakest  link  in  the  whole  mouth  hygiene  move- 
ment is  the  dentist  himself." 


CHAPTEE     II. 
ORAL  HYGIENE  FEOM  INFANCY. 

SOME  FUNDAMENTAL  OBSEKVATIONS. SIXTH  YEAK   MOLARS. — 

MASTICATION   OF  FOOD. — THE   NEGLECTED  MOUTH. 

Oral  hygiene  for  the  infant  should  start  at  its  birth, 
and  be  maintained  by  the  trained  nurse  until  the  child  is 
turned  over  to  the  regular  nurse  and  the  mother,  who 
in  turn,  should  be  taught  to  carry  out  our  instructions  for 
keeping  the  mouth  in  a  cleanly  condition.  Milk,  whether 
from  the  mother's  breast  or  the  cow,  readily  ferments 
in  an  exposed  warm  place,  such  as  the  child's  mouth. 

If  properly  done,  nothing  but  good  can  result  from 
washing  a  baby's  mouth.  The  manner  of  doing  this  is 
one  of  the  simplest  things,  and  yet,  in  mj^'  college  work, 
after  lecturing  on  the  subject,  I  have  found  that  few  stu- 
dents remembered  it  at  thei  time  of  their  final  examina- 
tions. The  first  requisite  is  clean  hands.  Around  the 
index  finger  is  wrapped  a  small  amount  of  aseptic  cotton ; 
the  cotton  is  then  saturated  with  a  solution  of  boric  acid. 
The  child  is  held  in  the  arms  with  the  head  slightly  back, 
and,  as  most  children  when  held  in  this  position  open 
their  mouths,  the  finger  can  be  inserted  easily.  The  part 
of  the  mouth  which  needs  the  most  attention  is  not  the 
top  of  the  gum  surface,  as  many  seem  to  think,  but  under 
the  tongue,  and  at  the  lower  surfaces  on  the  buccal  sides 
of  the  cheek  in  places  where  milk  remains.  Do  not  use 
gauze  on  the  finger  as  it  is  entirely  too  rough.  Rubbing 
is  not  necessary,  but  the  simple  cleansing  by  removing 
the  milk  debris  is  the  proper  idea.  The  best  time  for 
this  is  after  the  morning  bath  and  the  procedure  may 
be  repeated  at  night  with  good  results. 

"When  the  child  is  about  nine  months  old,  the  same 
method  is  used,  and,  in  addition,  care  should  be  exercised 
in  wiping  around  whatever  teeth  have  erupted  at  this 


Sixth  Yeae  Molaes.  13 

time.  About  the  tenth  month,  it  is  well  to  secure  a  soft 
camel's  hair  brush,  one  in  which  the  hairs  do  not  shed, 
and  very  carefully  brush  the  teeth  from  the  gums  with 
a  rotary  motion,  using  a  brush  which  has  been  dipped 
in  boric  acid  solution.  At  this  age,  the  child  will  not 
object  to  it,  and  it  should  be  .done  more  in  a  spirit  of 
play  by  the  mother  herself.  Now,  too,  the  child  will 
enjoy  the  friction  of  the  brush  upon  the  gums.  The  gums 
can  now  be  brushed  and  a  small  amount  of  massage  given. 
This  will  stimulate  the  growth  of  the  teeth  and  i3rove  to 
be  a  great  aid  towards  their  eruption.  If  the  spirit  of 
play  in  this  brushing  is  carried  out,  the  child  early  learns 
to  brush  its  own  teeth,  and,  if  kept  up,  the  tooth  brush 
habit  will  be  so  instilled  into  the  child's  mind  that  much 
pain  and  decayed  teeth  will  be  prevented  for  the  future 
man  or  woman. 

SIXTH  YEAR  MOLARS. 

Dr.  Woodbury,  of  Boston,  calls  the  sixth  year  molars 
the  "working  tools  of  mastication.  Their  work  begins 
at  once  and  lasts  throughout  life;  upon  them  rest  full 
growth  and  development;  upon  them  depends  good 
health  during  life. ' '  If  tliis  is  true,  Ave  have  the  key  note 
for  a  great  deal  of  dental  irregularities  due  to  mal-occlu- 
sion,  food  pockets,  contracted  jaws,  and  also  a  great 
many  pathological  conditions.  One  has  only  to  examine 
the  mouths  of  a  moderate  number  of  subjects  to  be 
astonished  at  the  early  removal  of  one  or  more  of  these 
sixth  year  molars.  As  these  teeth  come  out  just  back 
of  the  temporary  teeth,  the  parent  is  careless  about  the 
child  brushing  them  ]n'operly,  and  thinking  that  they, 
too,  are  temporary  teeth  to  be  soon  shed.  They  are 
generally  covered  with  a  mass  of  sticky  food  which 
furnishes  nutriment  for  germs  of  decay. 

In  examinations  which  I  have  made  at  the  ^'Plome  for 
the  Friendless,"  of  children  from  six  to  fifteen  years 
of  age,  in  our  city  hospitals,  and  among  students  of  the 
dental  colleges,  there  is  one  defect  more  than  all  others. 


14  Peactical  Oeal  Hygiene. 

and  that  is  this  condition  of  loss  of  the  sixth  year  molars, 
especially  in  the  lower  jaw.  If  it  were  only  the  simple 
loss  of  the  tooth,  it  would  not  be  so  bad,  but  nature, 
attempting  to  close  up  this  space,  tilts  the  next  four  or 
five  teeth,  causing  them  to  get  so  far  out  of  place  that 
the  proper  mastication  of  food  is  impossible. 


Fig.  1.    Models  of  a  Youn^g  Lady  21  Years  op  Age,  Showing  Irkeg- 

ULARiTY  Caused  by  the  Early  Loss  of  the  Sixth  Year  Molars. 

(Case  of  Dr.  C.   C.  Howard.) 

It  should  be  the  duty  of  all  teachers  of  oral  hygiene 
to  show  on  their  screens  pictures  illustrating  the  result 
of  this  condition  or  to  draw^them  on  the  blackboard. 

Dr.  Potter,  in  an  article  published  by  the  '' Dental 
Hygiene  Council,"  of  Massachusetts,  says,  in  reference 
to  the  statistics  which  he  rejDorted  in  Brookline,  Mass., 
"The  sixth  year  molar  has  aptly  been  styled  by  Dr.. 
Bogue,  the  principal  molar  of  man.  All  will,  I  believe, 
agree  with  this  designation.  If  tlie  tooth  is  in  large 
measure  or  wholly  destroyed,  the  efficiency  of  the  teeth,, 
as  masticating  powers,  is  largely  lost.  In  345  pupils, 
from  eleven  to  fourteen  years  of  age,  18  per  cent,  had 
lost  both  crowns  of  the  lower  sixth  year  molars,  and 
24  per  cent,  had  lost  one  crown  of  a  lower  sixth  year 
molar.     In  the  same  number  of  pujoils  at  the  same  age,. 


Masticatiox  of  Food.  15 

G.9  per  cent,  had  lost  both  crowns  of  their  upper  sixth 
year  molars,  and  13  per  cent,  had  lost  one  crown  of  their 
npper  sixth  year  molars." 

The  best  remedy  is  that  described  under  ''Technique 
of  Propltylaxis,"  which  is  the  covering  of  this  tooth  as 
soon  as  it  erupts,  but,  as  comparatively  few  people  to 
whom  we  talk  will  be  receiving  regular  prophylaxis  care 
from  a  dentist,  we  should  in  all  our  lectures  particularly 
stress  the  brushing  of  this  tooth. 

MASTICATIOlsr  OF  FOOD. 

In  our  former  races,  not  only  the  skulls  of  adults, 
but  of  children  as  well,  exhibit  a  smaller  number  of  caries 
than  we  are  accustomed  to  find  to-day.  This  is  undoubt- 
edly due  to  the  fact  that  they  had  coarse  food  to  chew, 
for  the  cusps  of  the  museum  specimens  are  worn  nearly 
to  the  pulp.  Such  a  thing  in  children  to-day  would  be 
a  dental  rarety.  Thus,  we  must  conclude  that  it  is  the 
duty  of  the  dentist  to  acquaint  their  patients  with  these 
facts,  and  instruct  them  always  to  provide  their  tables 
with  some  food  which  will  require  very  thorough  masti- 
cation. While  such  teaching  may  not  at  first  be  very 
popular,  there  are  many  of  our  good  patients  who  would 
undoubtedly  put  this  into  practice  if  acquainted  with  the 
beneficial  results  which  would  surely  ensue. 

It  is  unfortunate  that  the  temporary  teeth  of  our 
children,  just  at  the  stage  when  thorough  mastication  is 
of  greatest  importance,  are  allowed  to  decay  to  such  an 
extent  that  it  becomes  a  painful  operation  for  the  child 
to  masticate  food  at  all.  It  is  at  the  age  of  eight  or 
twelve  that  the  greatest  developments  should  take  place, 
but  the  examination  of  school  children  has  shown  that 
a  large  majority  of  them  are  dental  cripples.  It  is  time 
the  dental  profession  is  waking  up  to  its  opportunity 
and  duty,  and  trying  in  some  way  to  instil  into  the  minds 
of,  not  only  their  patients,  but  also  the  people  at  large, 
these  important  facts  about  the  care  of  the  teeth  and 


16  Peactical  Oral  Hygiexe. 

the  prevention  of  disease.  Instead  of  pies  and  soft  foods, 
the  children  should  be  taught  to  eat  the  food  which  re- 
quires thorough  mastication.  I  am  always  telling  my 
students  that  the  tough  meat  at  the  boarding  houses  is 
one  of  the  greatest  Godsends  which  they  have,  if  they 
will  only  take  advantage  of  it,  and  learn  to  thoroughly 
masticate  their  food.  I  have  been  told  that  some  of  them 
found  a  certain  amount  of  consolation  in  the  experiment. 
.  Nature  furnished  man's  jaw  with  a  series  of  muscles 
strongly  attached  to  the  jaw  bones,  in  order  that  the 
food  may  be  given  the  proper  amount  of  mastication. 
The  muscles  in  this  position  are  subject  to  the  same  laws 
of  development  and  increase  of  power  through  exercise 
as  the  muscles  in  other  parts  of  the  body.  It  is  a  fact 
which  can  be  easily  demonstrated  that  the  person  who 
chews  well  has  a  much  larger  set  of  muscles  than  the 
person  who  chews  but  little. 

It  having  been  shown  heretofore  that  primitive  man 's 
immunity  to  decay  was  due  to  the  perfect  mastication 
of  his  food.  The  one  factor  in  our  future  work  on  pro- 
phylaxis which  must  be  stressed  more  than  heretofore, 
is  the  use  of  our  jaws.  Dr.  Gr.  B.  Black,  in  his  book  on 
''Operative  Dentistry,"  has  an  instrument,  the  Gnatho- 
dynameter,  by  which  the  force  of  the  ordinary  bite  may 
be  measured.  This  has  been  found  equaled  to  three 
hundred  pounds.  Nature  certainly  intended  us  to  make 
use  of  this  tremendous  power  with  which  we  are  supplied. 
However,  we  are,  rmfortunately,  not  given  this  oppor- 
tunity often,  for  our  housewives  would  feel  chagrined  if 
there  appeared  upon  our  tables  am^thing  which  would 
necessitate  any  large  amount  of  chewing  before  it  is 
swallowed.  The  whole  idea  of  cooks  seems  to  be  to 
eliminate  anything  which  requires  much  mastication  and 
deprive  us  of  this  exercise  which  is  so  important  to 
health  and  comfort. 

The  idea  is  often  held  by  the  laity  that  the  teeth  are 
easily  injured  by  the  measures  for  cleaning  and  brushing 
them.     Many  of  the  patients,  I  have  found,  look  with 


The  Neglected  Mouth.  17 

horror  at  the  simple  cleaning  of  the  teeth,  or  the  direc- 
tions for  use  of  a  dentifrice,  with  the  idea  that  the  enamel 
of  the  teeth  can  be  easily  removed.  This  is  one  of  the 
illusions  that  I  first  try  to  get  out  of  the  minds  of  the 
freshman  dental  students,  as  well  as  the  new  patients 
who  come  for  prophylaxis.  They  must  be  brought  to 
realize  that  the  enamel  of  the  teeth  is  one  of  the  hardest 
substances  in  nature,  and  it  is  made  to  stand  the  hard 
usages  that  a  life  time  service  may  demand.  The 
abrasion  that  ensues  from  prophylaxis,  the  cleaning  of 
teeth,  and  the  brushing  of  teeth  -will  not  in  any  way 
measure  up  to  that  destruction  which  is  sure  to  follow 
the  lack  of  these  precautions. 

THE   NEGLECTED  MOUTH. 

By  editorial  in  the  Dental  Bispensary  Record  (March, 
1910)  Dr.  Belcher  thus  expressed  himself: 

''A  child  cannot  be  expected  to  develop  into  a  healthy 
adult  if  they  are  deprived  of  efficient  means  of  chewing 
their  food  properly,  or  if  the  food  must  pass  through 
an  uncared  for  mouth  that  is  more  like  a  cesspool  than  a 
receptacle  for  the  transmission  of  food  to  the  human 
body,  every  ounce  of  which  must  pass  through  this  dis- 
ease-breeding area  on  its  way  to  the  stomach,  burdened 
with  numerous  colonies  of  poisonous  germs,  of  which  over 
twenty  harmful  varieties  have  been  found  in  unclean 
mouths.  No  wonder  such  children  are  sickly  and  lacking 
in  strength  to  resist  disease,  or  that  they  are  not  con- 
sidered bright  and  intelligent,  and  figure  many  times  as 
members  of  our  mentally  deficient  classes  in  the  school 
work.  Not  only  this,  but  an  unclean  mouth  is  the  direct 
cause  of  many  ear  aches,  enlarged  tonsils,  adenoids, 
stomach  ills,  and  that  most  dreadful  of  children's  dis- 
eases, diphtheria,  is  invited." 

Under  the  title  of  ''Clean  Teeth  on  the  Market," 
Dental  Dispensary  Record  (March,  1911)  Dr.  Agnes  de 


18  Peactical  Oral  Hygiene. 


Fig.  2.     Child,  Age  Six,  With  Full  Complemekt  of  Deciduous 
Teeth.     Note  Symmetry  of  Features.. 

Second  Picture. — Same  eliikl.  Picture  taken  three  years  latei',  dur- 
ing which  time  the  four  six-year  molars  were  lost  through  neglect. 
Note  mal-development  of  jaws,  Avhich  is  partially,  if  not  entirely,  due 
to  the  absence  of  these  most  impoiiant  teeth.  (Case  of  Dr.  C.  C. 
Howard.) 

Lima  of  the  Bureau  of  Municipal  Eesearch  of  New  York, 
says: 

''Doctors  still  prescribe  tonics  for  invalids  whose  de- 
caying teeth  are  draining  their  vitality,  more  than  any 
other  cause,  and  fortunes  are  spent  to  attempt  to  cure  tu- 
bercular parents  who  reinfect  themselves  every  time  food, 
medicine  and  saliva  pass  over  their  diseased  cavities  and 
gums ;  millions  are  spent  on  purifying  the  water  supply 
and  the  soil ;  medical  institutes  are  endowed  to  stamp 
out  the  contamination  of  food  and  air  by  "pathogenic 
bacteria,"  but  the  prime  breeding  plan  for  germs — the 
human  mouth — is  neglected  and  uncared  for," 

From  the  same  journal,  (Nov.,  1912)  H.  N.  Holmes 
writes  some  strong  arguments : 

"When  the  slightest  eruption  of  the  skin  occurs,  from 
no  matter  what  cause,  we  begin  treatment  for  it,  and  if 


The  Neglected  Mouth. 


19 


it  doesn't  heal  in  a  short  time  we  consult  a  physician, 
and  if  he  fails  to  get  results,  we  are  thoroughly  aroused 
and  seek  a  specialist  without  delay,  but  with  the  mouth 
it  is  quite  the  reverse. 


Fig.  3.     Same  as  Fig.  2  at  Age  18.     Wixiiout  the  "Keys  to  the 

Arches"   (Six- Year  Molars)   Normal  Development  of  the 

Remaining  Teeth  Never  Occurs.    (Case  Dr.  C.  C.  Howard.) 

''Not  One  Person  in  Twenty  after  the  age  of  Thirty 
has  a  Mouth  in  a  Healtl^y  Condition,  and  not  One  in  Ten 
has  a  Mouth  Free  from  Pus  at  Any  Time. 

''We  wash  our  body  once  a  day  and  our  faces  and 
hands  several  times,  but,  alas,  some  of  us  have  our  mouths 
cleaned  once  or  twice  a  year — maybe.  Even  then  it  is 
seldom  well  done,  for  dentists  as  a  rule  slight  such  jobs, 
for  if  the  patients  haven't  enough  decency,  pride,  self- 
respect  or  what  you  may  term  it,  for  others,  than  to 
present  themselves  with  a  chloride  of  lime  breath,  far 
be  it  for  the  dentist  to  turn  iiolicoman  at  this  ago." 


CHAPTEE  III. 
POPULAE  LECTUEES  ON  DENTAL  SUBJECTS. 

TEETH       AND       THEIE       CAEE. DENTAL       SUMMAEY.  —  OUTLINE 

LECTUEES:    (1)   POK  MOTHEES'  CLUBS,    (2)    TO  CHILDEEN, 

(3)   FOE  NUESES  AND  PHYSICIANS,    (4)    TO 

KINDEEGAETEN. BY  STEVENSON. 

Tlie  subject  of  oral  hygiene  is  now  causing  such  inter- 
est that  even  dentists  in  small  towns  are  being  called 
on  to  deliver  lectures  before  the  various  schools  in  their 
localities.  This  often  places  the  dentist  in  a  difficult 
situation,  because,  in  the  first  place,  the  subject  is  new 
and  he  is  often  not  acquainted  with  it.  Dentists  are  not 
in  the  habit  of  writing  papers  and  delivering  lectures, 
and  this  new  request,  pu.t  before  them,  sometimes  startles 
them.  Again  the  subject  matter  is  hard  to  collect  and 
get  in  shape  for  a  suitable  lecture. 

Many  times  I  have  heard  of  lectures  that  were  utter 
failures  owing  to  the  fact  that  ,they  were  too  scientific 
and  did  not  give  elementary  facts.  Every  dentist  who 
does  any  lecturing  along  this  line  has  been  called  upon 
by  his  various  friends  for  facts  which  will  constitute  the 
right  sort  of  lecture  in  this  regard.  With  these  facts 
before  me,  I  have  determined  to  give  the  frame  work  of 
some  good  lectures  at  some  length,  so  as  to  meet  this 
rquirement.  One  of  the  best  that  was  furnished  me  on 
this  subject  was  sent  in  by  the  Dental  Summary,  issued 
by  the  Michigan  Dental  Society. 

While  this  lecture  seems  very  elementary,  it  was  de- 
livered l)efore  the  senior  class  of  a  high  class  female 
college,  and  the  results  which  followed  it  show  that  it 
contained  the  proper  material  for  this  kind  of  lecture. 
The  great  trouble  is  that  we  forget  how  little  the  people 
know  on  this  subject.  This  is  one  of  the  points  which 
will  have  to  be  guarded  against.    This  lecture  and  those 


PopuLAE  Lectures  on  Dental,  Subjects.  21 

following,  are  among  tlie  best  which  have  appeared  in 
dental  literature. 

A  LECTURE   ON   THE   TEETH. 

'^Eecent  examination  of  the  teeth  of  school  children 
in  many  parts  of  the  world  shows  that  about  9G  in  every 
100  children  have  diseased  teeth. 

' '  Think  of  it :  Only  about  four  children  in  a  hundred 
who  are  not  suffering  more  or  less  from  diseased  teeth. 

"This  would  be  bad  enough  if  the  toothache  were  all 
the  little  ones  had  to  suffer  as  the  result  of  somebody's 
neglect ;  but,  as  simply  a  matter  of  well  known  fact,  the 
toothache  is  the  smallest  part  of  the  trouble.  In  fact, 
toothache  is  not  the  trouble  at  all,  nor  any  part  of  the 
trouble;  it  is  simply  the  cry  of  the  nerve,  trying  to 
arouse  attention  of  the  fact  that  something  is  wrong; 
the  call  of  the  nerve  to  be  relieved  from  the  poison  that 
is  killing  it. 

"Statistics  show  that  on  account  of  poor  teeth  the 
mental  and  physical  development  of  the  child  is  seriously 
retarded. 

"The  more  the  physical  and  mental  development  of 
the  child  is  disturbed  and  retarded,  the  less  is,  of  course, 
the  general  capacity  of  the  child. 

"The  worse  the  teeth,  the  lower,  as  a  rule,  is  the 
school-standing  of  the  child. 

"Dr.  Luther  H.  Gulick,  of  New  York  City,  is  respon- 
sible for  the  statement  that  of  40^000  school  children 
examined,  those  with  two  or  more  bad  teeth  averaged 
five  months  behind  the  grades  that  they  should  occupy, 
and  Avould  occupy  were  their  teeth  sound.  Adenoids 
were  responsible  for  lagging  to  the  extent  of  eleven 
months. 

"As  decay  spreads  from  the  rotting  apple  to  the 
sound  one  by  its  side,  so  does  it  spread  from  the  first 
decayed  tooth  in  the  temporary  set  to  the  next  and  the 
next;  and  so  does  it  spread  from  decayed  first  tooth  to 


22  Peactical  Oral  Hygiene. 

sound  second,  or  permanent  one,  coming  in  alongside  of 
it.  In  a  very  short  time,  if  neglected,  tlie  second  teeth 
are  as  bad  as  the  first. 

"Because  of  poor  teeth,  the  child  swallows  its  food 
unchewed,  and  the  habit  of  bolting  is  formed.  The  youth 
also,  for  the  same  reason,  swallows  his  food  unchewed, 
and  the  habit  becomes  fixed.  The  unchewed  food  is  not 
digested;  indigestion  and  bowel  troubles  follow,  and  the 
child,  if  it  survive,  becomes  a  weakly,  undeveloped  man 
or  woman,  an  easy  prey  to  tuberculosis  and  the  host  of 
other  ills  that  prey  upon  people  of  low  general  vitality. 

"This  is  no  overdrawn  statement;  it  is  amply  proved 
by  experience  and  statistics. 

"Xo  claim  is  made,  of  course,  that  bad  teeth  are  the 
sole  cause  of  disease.  Abuse,  in  like  manner,  any  other 
part  or  organ  of  the  boch^,  as  important  as  the  teeth, 
and  disease  is  sure  to  follow. 

"Now,  a  very  large  part  of  this  suffering — the  half- 
starved  body  and  the  weak  brain  that  follows  it 
naturally,  grow  out  of  pure  neglect;  and  by  far  the 
greater  part  of  this  neglect  is  due  to  ignorance.  And  it 
seems  strange  indeed  that  the  world  should  have  been 
so  tardy  in  realizing  the  importance  of  the  teeth,  and 
the  necessity  for  their  intelligent  care.  This  condition 
of  ignorance  may  be  charged  to  what  seems  to  be  an 
innate  tendency  upon  the  part  of  scientific  men  generally 
to  dig  and  delve  in  search  of  the  obscure  and  the  com- 
paratively unimportant,  while  overlooking  the  much  more 
important  and  perfectly  obvious  facts  immediately  under 
their  observation. 

"Let  it  be  understood  at  the  outset  that  a  clean  mouth 
and  sound,  well  cared  for  teeth  are  positively  essential 
to  perfect  health;  even  to  the  average  of  good  health; 
and  that  such  teeth,  used  to  masticate  the  food  as 
intended  by  nature,  will  go  a  long  way  toward  inducing 
and  conserving  that  degree  of  health. 

"If  we  would  intelligently  care  for  the  teeth,  we  must 
first  learn  to  know  something  about  them;  how  many 


PopuLAE  Lectures  on  Dextal  Subjects.  23 

there  are  in  the  first  set  aucl  what  they  are;  how  many 
there  are  in  the  second  set  and  when  they  are  cut;  the 
relation  of  the  first  set  to  the  second,  etc. 

''It  will,  perhaps,  help  us  to  remember  the  number 
of  the  first  or  temporary  teeth  if  we  associate  them  with 
the  fingers  and  toes.  Ten  fingers — ten  temporary  teeth 
in  upper  jaw ;  ten  toes — ten  temporary  teeth  in  the  lower 
jaw;  five  on  either  side,  both  in  the  upper  and  lower 
jaw. 

''The  first  teeth  are  usually  all  in  by  the  end  of  the 
second  year.  The  first  to  be  cut  are  the  lower  front 
teeth,  the  central  incisors  appearing,  as  a  rule,  about  the 
seventh  month,  and  lasting  usually,  until  about  the  sev- 
enth year,  when  they  are  replaced  by  the  permanent 
incisors. 

"The  incisors  are  the  cutting  teeth.  From  the  same 
root  word  we  have  the  word  'scissors,'  you  know. 

"The  other  temporary  teeth  appear  at  short  inter- 
vals, until,  by  the  end  of  the  second  year,  the  entire 
twenty  are  in  place. 

"Now,  it  is  of  the  utmost  importance  that  these 
twenty  teeth  remain  in  place  with  their  crowns  undim- 
inished in  size  by  decay,  until  the  loermanent  teeth  are 
ready  to  replace  them.  The  first  teeth  should  be  dis- 
placed and  pushed  out  by  the  second  or  permanent  set. 
Why  is  this  so  important?  Many  parents  think  that  the 
first  teeth  amount  to  very  little,  and  the  sooner  they  are 
gotten  rid  of  the  better.  There  could  not  be  a  more 
serious  mistake.    Let  us  see. 

"We  already  have  considered  the  effect  that  decayed 
and  aching  teeth  have  upon  the  habit  of  chewing  the  food. 
Teeth,  especially  teeth  that  are  just  coming  in,  require 
exercise  precisely  as  do  other  parts  of  the  growing  body. 
When  the  first  teeth  are  decayed,  painful  or  lost,  the 
permanent  teeth  do  not  liave  the  exercise  they  need,  be- 
cause the  food  is  bolted ;  that  is,  swallowed  without  being 
chewed,  or  after  beiug  only  partially  masticated.     And 


24  Peactical,  Oeal  Hygiene. 

there  is  another  reason  why  the  retention  of  the  first 
teeth  is  so  important : 

^' About  the  time  that  the  first  front  teeth  are  begin- 
ning to  loosen,  anotlier  tooth,  the  largest  and  most  im- 
porant  tooth  of  all,  is  pusEIng  its  way  up  through  the 
gnm,  right  behind  the  first  'baby  molar,'  or  double  tooth. 
If  this  last  baby  tooth  or  those  in  front  of  it,  have  been 
made  narrower  than  normal,  or  have  been  lost  altogether 
on  account  of  decay  or  premature  extraction,  this  big, 
new  tooth,  which  is  a  permanent  one,  the  sixth  from  the 
center  in  front,  and  coming  in  at  the  sixth  year  of  age, 
and  not  being  guided  into  its  proper  place  and  kept  there 
by  sound  first  teeth,  comes  in  out  of  place,  too  far 
forward. 

'^  Sometimes  it  is  the  width  of  the  tooth,  sometimes  the 
width  of  the  whole  tooth,  too  far  toward  the  front.  AA^iat 
difference  does  that  make,  some  may  ask?  Isn't  the  tooth 
there?  Will  not  the  other  teeth,  coming  in  later,  force 
it  to  its  proper  place?  No;  that's  just  the  difference  it 
makes;  that's  just  the  trouble. 

''When  the  first  big,  strong,  permanent,  most  im- 
portant tooth  comes  in  too  far  forward,  the  jaw  is  short- 
ened by  just  that  much,  and  it  remains  too  short. 

"It  is  generally  supposed  that  the  jaw  controlls  the 
location  of  the  teeth  in  what  is  called  the  arch;  that  is, 
the  semi-circle  in  which  the  teeth  are  located;  but  that 
is  only  another  of  the  many  mistakes  most  people  hold 
in  regard  to  the  teeth.  The  jaw  does  not  control  the 
teeth,  but  the  teeth  control  the  size  and  the  shape  of  the 
jaw. 

"Now,  into  this  shortened  jaw,  in  front  of  the  sixth- 
year  molar,  five  permanent  teeth  must  find  a  place.  How 
are  they  going  to  do  it?  Well,  most  of  you  have  seen 
mouths  filled  with  crowded,  jumbled,  crooked,  overlap- 
ping teeth;  and  that's  how  they  do  it.  They  come  in 
where  they  can,  following  the  line  of  least  resistance,, 
with  nothing  to  guide  them.  (*) 


Popular  Lectures  on  Dental  Subjects.  25 

"The  sixth  tooth,  the  six-year  molar,  coming  as  it 
should  do  and  usually  does,  before  the  first  or  temporary 
teeth  are  lost,  is  usually  regarded  as  a  temporary  tooth 
also,  and  is  allowed  to  decay,  even  by  joarents  who  mean 
to  give  their  children  the  best  of  care,  under  the  mis- 
taken impression  that  it  will  soon  be  replaced  by  another 
and  a  permanent  one.  But  it  will  ne^^er  be  replaced. 
The  six-year  molars,  and  all  the  other  molars,  are  cut  but 
once;  once  lost  they  are  gone  forever.  They  never  will 
be  replaced,  excejat  by  artificial  substitutes,  a  very  poor 
dependence  at  best. 

"And  this  six-year  molar  is  the  most  important  of  all 
the  teeth.  Upon  its  proper  location  and  preservation 
depends,  to  a  very  large  degree,  the  safety,  the  beauty 
and  the  usefulness  of  all  the  other  teeth. 

"When  the  teeth  are  all  in  their  proper  positions, 
they  form  a  beautiful  even  curve,  the  sort  of  curved  line 
that  nature  delights  in ;  and  the  features  possess  the  con- 
tour and  balance  that  make  the  face  so  attractive. 

"When  the  teeth  are  lost,  or  all  jumbled  together, 
the  jaws  are  too  small,  the  lips  hang  open,  and  the 
harmony  of  the  face  is  marred,  when  not  entirely 
destroyed.  (*) 

"There  is,  of  course,  a  much  more  important  phase 
of  the  subject  than  mere  appearance,  although  that  is 
certainly  important  enough,  often  making  or  marring 
the  entire  life.  The  more  imj^ortant  fact  is  the  use  of 
the  teeth  as  they  should  be  used,  to  conserve  health  and 
strength  of  the  entire  body. 

"When  the  teeth  are  all  in  their  proper  places,  and 
stand  at  the  proper  angle  with  the  jaw,  the  grinding 
surfaces  of  the  upper  and  lower  teeth  fit  together  very 
closely;  and,  like  the  mills  of  the  gods,  they  grind  ex- 
ceedingly fine,  preparing  the  food  as  it  ought  to  be  for 
the  digestive  process  that  follows.  But  if  one  is  lost,  es- 
pecially if  that  one  be  this  first  permanent  molar,  the 
grinding  surfaces  drift  apart ;  and,  if  the  difficulty  is  not 


26  Peaotical  Okal  Hygiexe. 

quickly  and  sldlfully  remedied,  the  worlv  tliat  the  teeth 
should  do,  never  can  be  done  properly. 

"Then,  too,  of  course,  crowded  and  irregular  teeth 
are  much  more  difficult  to  care  for,  to  keep  clean,  they 
are  much  more  likely  to  decay,  and  the  gums  are  mucli 
more  subject  to  disease. 

"Remember,  then,  that  the  tooth  coming  in  at  the 
sixth  year,  the  sixth  tooth  from  the  center  in  front,  is 
the  first  of  the  thirty-two  permanent  teeth,  which,  with 
the  care  that  all  of  the  teeth  should  have,  ought  to  last 
each  of  us  to  the  end  of  life.  (**) 

"If  the  child  is  to  have  strong,  tough,  resistant  teeth, 
it  is  essential  that  its  food  contain  an  ample  supply  of 
the  bone-building  salts  of  lime.  These  salts  are  essential 
for  other  purposes  as  well.  When  it  is  known  that  the 
epidermis  or  skin,  the  bones  and  the  teeth  are  all  built 
of  the  same  kind  of  cells,  and  that  these  cells  depend 
for  their  perfection  upon  salts  of  lime,  the  importance  of 
this  kind  of  food  readily  will  be  recognized. 

"The  bottle-fed  baby,  brought  up  on  the  prepared 
foods  so  abundantly  on  the  market  at  this  time,  starts 
life  with  a  ver}''  serious  handicap.  According  to  the 
authority  of  scientific  men,  who  are  making  these  sub- 
jects the  study  of  their  lives,  these  prepared  foods,  nearly 
all  of  them,  are  altogether  deficient  in  the  bone-building 
elements. 

"Tlie  best  substitute  for  the  nursing  baby's  natural 
food  is  cow's  milk.  Don't  forget  this;  don't  be  deceived 
by  alluring  advertisements  written  by  men  who  either  do 
not  know  or  care  to  know  what  they  are  talking  about. 

"The  eruption,  or  cutting  of  the  deciduous,  or  tempo- 
rary, or  first  molars,  indicates  that  the  system  of  the 
child  is  ready  to  assimilate  solid  foods,  and  if  he  is  given 
really  solid  foods,  and  taught  to  thoroughly  masticate 
them,  it  will  be  well  with  that  child 

"Every  meal  should  contain  something  that  requires 
good,  vigorous  chewing;  like  every  other  part  of  the  body, 


Popular  Lectures  o:n  Dental  Subjects.  27 

tlie  teeth,  gums  and  jaws  require  and  are  developed  by 
exercise,  and  suffer  from  lack  of  it. 

''Among  the  foods  rich  in  the  bone-building  phos- 
phates of  lime,  wheat  stands  high.  But,  in  the  process 
of  making  fine,  white  flour,  half  of  the  lime-salts  are  lost 
and  withdrawn  with  the  bran.  AVhole-wheat  liread,  while 
usually  not  so  easily  digested,  is  a  much  better  bone- 
builder,  and  any  form  of  Avhole-wheat,  containing  every 
particle  of  the  grain  as  nature  makes  it,  is  a  perfect  food, 
and  should  be  largely  used. 

"No  bread  should  be  eaten  until  it  is  twenty-four 
hours  old.  Fresh  bread,  especially  that  made  from  fine, 
white  flour,  forms  a  soggy,  fermenting  mass  in  the  sto- 
mach, and  is  not  only  very  indigestible,  but  furnishes 
a  breeding-place  for  the  germs  of  fermentation,  result- 
ing in  sour  stomach,  colic  and  many  other  ills. 

' '  Whole  wheat  and  whole  wheat  preparations,  such  as 
shredded-wheat,  triscuit,  etc.,  are  excellent.  Eggs,  oat- 
meal, cornmeal,  rice,  and  nearly  ail  vegetables  contain 
the  lime-salts  essential  to  bone-building.  So,  also  does 
beef.  A  simple  diet,  mixed,  composed  of  the  natural 
foods,  will  contain  all  of  the  elements  necessary  to  good 
health  and  good  teeth,  provided  they  are  well  masticated, 
and  i^rovided  also  that  digestion  and  assimilation  are  not 
impaired. 

''Experiments  made  over  and  over  again  prove  that 
animals  fed  on  poor  foods,  that  is,  such  as  are  deficient 
in  mineral  salts  of  the  kinds  necessary  to  body-building, 
have  poor  teeth  and  weak  bones ;  and  that,  if  such  foocls 
are  continued,  animals  will  starve  to  death  rather  than 
eat  it.  In  this  the  animals  are  guided  by  a  sure  instinct 
that  no  amount  of  'tasting  good'  can  deceive. 

"Adding  the  necessary  salts  to  the  food  artificially 
or  giving  them  in  doses  as  medicines,  does  not  alter  the 
case  in  the  least. 

"These  experiments  and  their  results  a]iply  equally 
to  the  child.  If  it  is  unable  to  obtain  a  sufficient  supply 
of  the  necessary  salts  from  a  mixed  diet  of  natural  foods, 


28  Pkactical  Oral,  Hygiene. 

the  use  of  bone-meal,  or  the  so-called  bone-building  drugs, 
is  likely  to  prove  of  no  avail. 

"Whatever  promotes  good  health — air,  sunshine,  nu- 
tritious foods  well  chewed,  hygienic  surroundings  at  all 
times,  plenty  of  sleep,  good  habits,  all  these  tend  toward 
the  building  up  of  good,  strong,  solid,  healthy  teeth. 

"Good  teeth  being  acquired,  good  care  is  necessary  in 
order  to  preserve  them  during  life.  If  the  teeth  are  not 
good,  if  they  are  soft,  decay  easily,  or  are  lacking  in  any 
degree,  they  require  even  greater  care  than  good  teeth. 
With  propr  care,  even  poor  teeth  may  be  preserved  al- 
most indefinitely.  "* 

"Until  within  the  last  few  years  dentistry  has  con- 
cerned itself  chiefly  with  repairing  the  damage  done  to 
the  teeth  by  decay,  and  with  replacing  them  with  artificial 
substitutes  when  too  far  gone  to  be  saved. 

"To-day  the  aim  of  progressive  dentistry  is  to  pre- 
vent dental  disorders  rather  than  to  cure  them. 

"To  keep  the  teeth  clean,  highly  polished,  free  from 
all  sharp  angles,  irritating  deposits,  fields  for  the  pro- 
duction of  pathogenic  or  disease-breeding  germs,  or  what- 
ever tends  to  invite  disease  or  promote  decay,  is  the 
most  useful  field  for  the  exercise  of  the  best  skill  of  the 
progressive  dentist.  In  other  words  modern  dentistry 
aims  to  put  the  mouth  into  h3''gienic  condition  and  keep 
it  there. 

"The  special  method  employed  to  bring  about  this 
natural,  healthy,  hygienic  condition,  and  to  maintain  it 
after  it  has  been  brought  about,  is  known  as  prophylaxis 
— oral  propyhlaxis.  Oral  refers  to  the  mouth;  prophy- 
laxis means  warding  off  or  preventing  disease;  or  that 
which  makes  for  the  preservation  of  good  health.  Oral 
prophylaxis  then,  means  treatment  that  is  efficacious  in 
the  prevention  of  dental  disorders ;  of  diseases  of  the 
mouth  and  the  teeth,  and  of  conditions  in  the  oral  cavity 
tending  to  cause  diseases  in  other  parts  of  the  body. 

"So  important  has  this  preventive  idea  become  in  the 
minds  of  the  dental  profession  that  there  are  now.  i,n 


Popular  Lectures  on  Dental  Subjects.  29 

many  cities,  prophylaxis  specialists,  who  devote  their 
entire  time  to  the  practice  of  this  important  branch  of 
dentistry. 

■^'The  creed:  of  oral  prophjiaxis  is  that  cleanliness  is 
the  salvation  of  the  teeth;  that  a  clean  mouth  and  clean 
teeth  mean  a  healthy  mouth  and  sound  teeth;  and,  as  a 
natural  consequence,  a  bettered,  more  resistant,  physical 
condition  generally. 

"Based  upon  statistics,  it  is  estimated  that  72  men, 
women  and  children  die  every  hour  in  the  United  States 
from  diseases  that  might  be  prevented;  and  it  is  now 
known  that  many  of  these  preventable  diseases  have  their 
origin  in  an  unhygienic  condition  of  the  mouth  and  teeth. 

"The  aim  of  oral  prophylaxis  is  to  do  its  share  and 
a  large  share,  in  the  prevention  of  this  needless  loss  of 
life ;  to  bring  about  a  condition  of  health  and  well-being 
so  far  as  the  mouth  and  teeth  are  concerned;  to  keep 
that  part  of  the  digestive  tract  that  is  under  our  control 
in  a  normal,  healthful  condition ;  and,  with  the  help  of 
the  patient,  to  keep  it  there  permanently. 

"How  is  the  patient  going  to  do  his  share  in  the  work 
of  maintaining  the  health  of  the  oral  cavity?  Certainly 
not  by  the  ordinary  thirty-second-lick-and-promise  clean- 
ing indulged  in  by  the  vast  majority  of  people  who  use 
the  tooth-brush. 

"In  the  first  place,  it  must  be  understood  that  the 
purpose  of  the  cleaning  is  not  merely  to  make  the  front 
teeth  fit  to  be  seen,  but  to  make  all  of  the  teeth,  on  all 
of  their  surfaces,  positively  clean.  And  this  means  in- 
telligent and  conscientious  effort,  regularly  and  faith- 
fully applied. 

"To  properly  clean  the  teeth,  begin  by  rinsing  the 
mouth  with  salt  water,  about  a  teaspoonful  of  salt  to  a 
pint  of  water,  warm  or  cold,  as  may  be  preferred,  forcing- 
it  vigorously  back  and  forth  between  the  teeth.  Do  this 
with  the  same  vigor  and  determination  that  you  would 
put  into  doing  any  thing  that  you  thought  would  ]^vo- 
long  your  life,  increase  its  happiness  or  usefulness,  or 


30  Peactical  Oeal  Hygiene, 

increase  your  income.  It  is  just  as  important  as  proper 
mastication,  or  as  the  proper  setting  of  a  broken  arm. 

''After  using  the  salt  water,  put  a  quantity  of  good 
tooth-powder  into  the  palm  of  one  hand,  with  the  other 
moisten  a  good  tooth-brush  with  the  salt  water,  and  dip 
it  into  the  powder.    Then  proceed  to  scoue  the  teeth. 

''Use  the  tooth-brush  as  you  would  a  scrubbing-brush 
on  your  kitchen  floor  or  in  your  bath  tub.  Scrub  your 
teeth;  do  not  be  satisfied  merely  to  brush  lightly  over 
the  surfaces. 

"Do  not  use  the  brush  crosswise  of  the  teeth.  You 
will  only  touch  the  high  surfaces  that  are  naturally  elean^ 
anyhow,  and  you  may  work  great  injury  by  sawing  cavi- 
ties in  the  teeth  above  the  enamel,  at  the  gum-line. 

"Begin  at  the  gums  on  the  upper  jaw  and  brush 
downward ;  begin  at  the  gums  on  the  lower  jaw  and  brush 
upward;  inside  and  outside  alike.  As  the  inside  or  the 
tongue  side  of  the  teeth  is  harder  to  reach  with  the  brush 
than  the  outside,  more  time  and  care  are  necessary  to  get 
them  clean  and  keep  them  clean.  As  a  lamentable  matter 
of  fact,  it  must  be  said  that  because  they  are  not  seen 
they  usually  get  much  less  care.  Ignorance  on  this  score 
is  much  to  he  lamented.  A  wealthy,  prosperous  and  suc- 
cessful man  of  sixty,  recently  stated  that  until  he  was 
well  past  fifty,  he  never  had  tried  to  clean  the  insides  of 
the  teeth,  thinking  that  they  did  not  need  any  care  at  all. 

"Scour  the  grinding  surfaces  back  and  forth,  cross- 
wise. Dip  the  brush  into  the  powder  often  enough  to 
apply  it  equally  to  all  of  the  teeth,  and  remember  that 
the  surfaces  that  are  the  hardest  to  reach  need  cleaning 
most. 

"Make  the  cleaning  of  the  teeth  as  necessary  to  your 
comfort  as  the  bath,  or  the  washing  of  the  hands  and 
face.  It  is  far  more  important.  Take  plenty  of  time. 
Ten  to  fifteen  minutes  per  day  is  none  too  much  time  to 
spend  at  this  most  important  Avork;  make  work  of  it; 
make  it  a  duty.  The  teetli  should  have  three  to  five 
cleanings  each  day,  in  addition  to  the  thorough  scrubbing- 


POPULAK  LeCTUEES  OlST  DeNTAL  SUBJECTS.  31 

described.  Eemember,  that  the  mouth  is  a  veritable 
breediug-grouud  for  disease-germs,  and  that  they  mnlti- 
-plj  with  astonishing  rapidity  if  undisturbed,  while  the 
raking  and  scraping  given  to  them  by  the  pro^Der  use  of 
the  brush,  to  say  nothing  of  the  frequent  dosing  with 
disinfectant  germicides  in  the  shape  of  tooth-powders 
and  mouth-washes,  prevent  their  increase  almost  wholly. 

''Two  or  more  tooth-brushes  should  be  used,  of  a 
rather  small  or  medium  size,  preferably  those  with 
wedge-shaped  points  on  the  rows  of  bristles,  as  the  points 
work  in  between  the  teeth,  where  most  care  is  necessary. 
Use  your  brushes  alternately,  so  that  they  will  have  a 
chance  to  dry  out  before  being  used  again.  Never  buy 
a  cheap  brush.  And  never  use  a  brush,  no  matter  how 
much  you  pay  for  it,  after  the  bristles  begin  to  fall  out. 
An  over-used,  soft  brush,  is  the  poorest  kind  of  economy. 
After  using  the  brush,  rinse  it  thoroughly  in  the  salt- 
water and  hang  it  on  the  rack  to  dry.  Any  good  mouth- 
wash will  do  in  |)lace  of  the  salt-water.  Powder  need 
be  used  in  most  mouths  but  once  each  day,  preferably 
at  bed-time,  if  used  as  suggested. 

"A  larger  proportion  of  the  cavities  in  teeth  start 
between  them,  where  the  brush,  however  skilfully  used, 
cannot  reach.  To  thoroughly  clean  these  spaces  is,  there- 
fore, of  utmost  importance.  For  this,  waxed  floss  silk, 
preferably  flat,  should  be  used.  Insert  between  the  teeth, 
and  draw  back  and  forth  until  all  these  surfaces  are  per- 
fectly clean.  Do  this  at  least  twice  each  day;  better,  do 
it  after  each  meal. 

"Be  careful  in  the  selection  and  use  of  tooth-picks. 
If  wood  is  used,  select  those  of  some  wood  of  dense  close 
grain,  that  does  not  splinter,  such  as  orange-wood.  The 
end  of  the  i3ick  used  between  the  teeth  should  be  flat. 
Picks  are  made  of  special  woods  and  rendered  antiseptic 
b}"  being  treated  with  aromatic  solutions  which  aid  in  the 
preservation  of  the  health  of  the  spaces  between  the 
teeth.  Be  careful  not  to  puncture  or  irritate  the  gums-, 
when  picking  the  teeth. 


32  Peacticajl  Oral  Hygiene. 

"It  is  no  easy  matter  to  teach  the  children  to  keep 
their  teeth  clean,  but  the  necessity  of  the  case  makes  it 
the  duty  of  every  parent  to  keep  constantly  at  their  child- 
ren until  the  habit  becomes  fixed. 

"In  spite  of  the  best  care  we  are  able  to  give  our 
teeth,  deposits  will  slowly  form  on  them  in  most  mouths, 
and  there  will  still  be  some  decay.  Therefore,  it  is  neces- 
sary to  visit  the  dentist  at  regular  intervals.  The  fre- 
quency of  these  visits  should  be  governed  by  the  needs 
of  the  individual,  and  this  should  be  left  to  the  knowl- 
edge and  judgment  of  the  dentist.  In  very  few  cases 
should  these  visits  be  less  frequent  than  twice  each  year. 

"As  to  why  teeth  decay,  an  illustration  may  help  to 
make  the  cause  and  process  clear.  If  a  drop,  of  acid  is 
spilled  upon  the  marbel  top  of  a  wash-stand,  it  boils  and 
bubbles,  and,  if  allowed  to  remain,  will  dissolve  out  the 
lime  and  leave  the  surface  roughened.  Nearly  everybody 
is  familiar  with  the  experiment  of  soaking  an  egg  in  vine- 
gar until  the  lime  in  the  shell  has  been  dissolved,  and 
the  egg,  unbroken,  then  put  into  a  bottle,  having  a  neck 
half  the  normal  size  of  the  egg.  Decay  of  a  tooth  is 
caused  by  a  similar  process  of  dissolving  the  lime. 

"The  lime  in  the  tooth  is  eaten  by  an  acid.  This 
•acid  is  known  as  lactic  acid,  familiar  to  nearly  everyone. 
It  is  the  acid  present  in  sour  milk.  Its  presence  in  the 
mouth  is  due  to  the  fermentation  or  souring  of  food  par- 
ticles adhering  to  and  between  the  teeth. 

"In  the  mouth  that  is  not  cared  for,  the  teeth  are 
bathed  in  this  acid  practical^  all  of  the  time,  and  all 
the  time  the  acid  is  at  work,  dissolving  out  the  lime-salts 
in  the  teeth,  ji^st  as  the  acids  do  with  the  marble  slab 
and  the  egg  shell.  This  shows  why  teeth  start  to  decay 
at  the  points  that  are  hardest  to  keep  clean.  It  also 
shows  why  extra  care  should  be  taken  to  keep  those  points 
as  clean  as  possible.  Decay  rarely  starts  on  the  exposed 
surfaces  of  a  tooth. 

"Now,  as  to  the  structure  of  a  tooth.  A  tooth  con- 
sists of  the  crown  (the  part  above  the  gum),  and  one  or 


POPULAK  LeCTUKES  ON  DeNTAL  SUBJECTS.       33 

more  roots  embedded  in  the  jaw.  The  outer  coatiDg  of 
the  tooth,  the  part  that  we  see,  is  called  the  enamel.  It 
is  nearly  all  lime-salts,  98  per  cent.  It  is  very  hard,  very 
compact,  comparatively  thin,  and  has  no  nerves;  there- 
fore, it  is  without  feeling.  Its  purpose  is  to  stand  the 
wear  of  grinding,  and  to  protect  the  softer,  sensitive 
parts  of  the  tooth  beneath.  (***) 

"Beneath  the  enamel  is  the  dentine.  It  forms  the 
bulk  of  the  tooth.  It  is  only  about  three-quarters,  75 
per  cent,  lime,  and  is,  of  course,  not  so  hard  as  the 
enamel.  It  is  something  like  bone,  having  tubes  and  hol- 
low jDlaces,  within  it,  along  which  the  germs  of  decay 
can  spread  and  multiply  without  much  resistance. 

"In  the  center  of  the  tooth,  surrounded  by  the  den- 
tine is  the  pulp,  commonly  but  improperly  called  the 
nerve.  It  has  a  great  many  exceedingly  fine,  thread-like 
branches  outwardly  through  the  dentine,  forming  a  very 
complete  signal-service,  the  duty  of  which  is  to  warn 
us  when  danger  from  decay  or  other  source  threatens 
the  health  and  usefulness  of  the  tooth. 

"A  tooth  that  aches,  after  one  has  been  eating,  for 
instance,  is  a  tooth  in  distress.  Some  of  the  little  pulp- 
branches  are  exposed  and  are  calling  for  protection.  If 
they  do  not  get  it,  the  pulp  itself  will  be  calling  next, 
and  by  that  time  the  chances  are  that  the  labor,  pain  and 
expense  of  saving  the  tooth  have  been  increased  mnnv 
fold. 

"Here  is  a  case  in  which  a  stitch  in  time  may  save 
not  only  a  great  deal  of  suffering,  but,  by  a  simple,  inex- 
pensive filling,  the  tooth  may  be  saved  to  usefulness  and 
comfort.  If,  on  the  other  hand,  the  warning  is  not  heeded, 
the  pulp,  after  protesting  with  all  its  might  with  some 
pretty  severe  aches  and  pains  commonly  called  neuralgia 
and  other  things,  gives  up  the  fight  and  dies.  Because 
the  pain  is  felt  not  so  much  in  that  particular  tooth 
as  all  over  the  face  on  that  side,  the  tooth  may  not  be 
suspected,  and  frequently  physician's  bills  of  large  size 
are  contracted  in  the  vain  search  for  relief. 


34  Peactical  Okal  Hygiene. 

'^  Facial  neuralgia,  so-called,  of  this  character  and 
from  this  cause,  is  very  common.  Facial  neuralgia  from 
all  other  causes  combined  is  very,  very  rare.  Therefore, 
when  suffering  from  neuralgia  in  the  face,  suspect  your 
teeth,  and  at  once  consult  the  dentist. 

"It  is  a  common  notion  that  a  tooth  having  a  dead 
nerve  or  pulp  can  ache  no  more.  This  is  a  delusion.  A 
dead  tooth,  like  any  other  unburied  dead  thing,  is  dan- 
gerous, a  menace  to  the  health  not  only  of  the  mouth, 
but  of  the  entire  body.  It  is  a  breeder  of  poisonous 
germs.  If  these  poisons  escape  into  the  mouth,  they  are 
mixed  with  the  food  and  the  saliva  and  swallowed.  And, 
in  the  case  of  mouth-breathers  especially,  the  foul  gases 
created  are  carried  to  the  lungs  and  thence  to  the  blood, 
paving  the  way  for  tuberculosis  and  a  general  undermin- 
ing of  the  health. 

"To  one  who  knows  how  vile  a  dead  pulp  becomes, 
the  very  thought  of  having  one  in  the  mouth  makes 
him  sick.  And  how,  are  we  to  have  pure  air  in  our  homes, 
our  schools,  our  opera-houses,  our  churches,  when,  with 
every  breath  from  such  a  mouth,  these  poisons  are  poured 
into  the  atmosi^here?  As  a  matter  of  simple  self-pro- 
tection, we  should  avoid  inhaling  the  breath  from  such 
a  mouth. 

"If,  instead  of  escaping  into  the  mouth,  the  poison- 
ous gases  get  out  through  the  end  of  the  root,  the  tooth 
becomes  sore,  the  face  swells,  pus  is  formed  and  bores 
its  way,  usually  with  great  pain,  out  through  the  jaw- 
bone and  gum,  forming  the  so-called  gum-boil.  This  pus. 
is  also  a  poison,  a  dead  thing;  and  this,  too,  is  swallowed, 
making  a  much  more  serious  condition  than  generally  is 
known,  or  may  generally  be  believed.  No  one  can  long- 
be  well  under  such  a  state  of  affairs,  a  veritable  poison 
factory  within  the  mouth. 

"Many  people  are  constantly  ill,  constantly  under  the 
care  of  the  physician,  doctoring  for  all  sorts  of  troubles, 
who  are  simply  the  victims  of  blood-poisoning,  due  tO' 


POPULAK  LeCTUKES  ON  DeNTAL   SUBJECTS.  35 

neglected  teeth.  Tlie  troubles  commonly  calld  'nervous 
diseases'  are  largely  due  to  these  causes. 

"Every  year  thousands  of  preventable  deaths  occur 
from  causes  originating  in  the  condition  described,  al- 
though very  seldom  is  the  true  condition  suspected  by 
anybody — except  the  dentist.  He  doesn't  suspect;  he 
knows. 

''Offensive  as  is  a  tooth  of  this  character  and  in  this 
condition,  and  dangerous  as  it  is  to  health,  and  life  itself,, 
it  may  be  restored  to  full  usefulness,  health  and  comfort. 
While  it  is  very  desirable  to  have  the  teeth  frequently 
examined  and  all  the  cavities  filled  while  small,  a  tooth 
is  not  beyond  redemption  and  salvation  even  when  noth- 
ing is  left  of  it  except  the  root,  providing  that  root  is 
firmly  held  in  its  socket.  A  root  broken  off  level  with 
the  gums  may  be  crowned  so  skilfully  as  to  appear  per- 
fectly natural  and  defy  detection,  and  it  may  be  so  ap- 
plied as  to  be  as  comfortable,  as  serviceable,  and,  in  many 
cases  more  lasting,  than  a  well-cared-for  natural  tooth, 
that  is  perfectly  sound. 

"Another  disease  to  which  neglected  teeth  are  sub- 
ject, is  loosening,  due  to  deposits  of  lime  in  the  form  of 
tartar,  and  to  collections  of  decaying  matter,  which  are 
allowed  to  gather  and  remain  on  them.  This  causes  the 
gums  to  swell,  to  become  tender,  to  bleed  easily,  and 
gradually  to  waste  away,  together  with  the  bony  socket 
that  holds  the  teeth  in  place. 

"This  is  a  very  serious  condition,  not  only  preventing 
the  proper  chewing  of  the  food,  because  of  the  tenderness 
of  the  teeth  and  gmms,  but  the  teeth  themselves  become 
exceedingly  filthy,  and  in  mam^  cases  large  quantities 
of  very  rank  pus  are  being  continually  swallowed,  the 
health  being  thus  most  surely  and  certainly  undermined 
by  the  two  enemies,  which  ably  aid  and  abet  each  other, 
one  by  preventing  proper  preparations  of  the  food  by  the 
teeth,  and  the  other  by  converting  much  of  it  into  rank 
poison. 


36  Pkactical  Oral  Hygiene. 

"If  this  trouble  is  attended  to  in  its  early  stages,  it 
may  be  removed  and  the  loose  teeth  tightened  and  re- 
stored to  perfect  usefulness;  but  if  neglected,  the  teeth 
finally  will  fall  out,  ending  the  chapter  in  disaster. 

"Here,  again  absolute  cleanliness  is  the  great  pre- 
ventive. Teeth  that  are  kept  clean  cannot  possibly  get 
into  this  distressing  and  often  fatal  condition.  Here 
again,  dirt,  decay,  degeneracy  and  death  go  hand  in  hand 
together. 

"This  disease,  in  common  with  most  of  those  to  which 
human  flesh  is  heir,  is  much  more  easily  prevented  than 
cured.  Those  who  are  threatened  with  it  or  suspect  that 
they  are,  should  lose  no  time  in  putting  themselves  under 
the  care  of  a  competent  dentist,  and  then  follow  re- 
ligiously and  rigorously  the  instructions  given. 

"The  expression,  'My  teeth  are  naturally  so  poor 
that  I  am  going  to  let  them  go  and  have  artificial  ones,' 
is  very  often  heard  from  the  lips  of  even  comparatively 
3^oung  people ;  and,  while  it  implies  a  compliment  to  the 
skill  of  the  modern  plate-maker,  the  thought  back  of  it 
is  usually  a  very  unwise  one  to  entertain,  and  the  course 
a  most  foolish  and  unsatisfactory  one  to  pursue.  It  is 
hard  to  imagine  a  set  of  natural  teeth  that  are  not  or 
cannot  be  made  much  more  useful,  satisfactory,  sanitary 
and  comfortable  than  the  best  plate  ever  turned  out  of 
a  dental  laboratory.  This  attitude  has  been  responsible 
for  the  heedless  loss  of  millions  upon  millions  of  per- 
fectly sound  teeth.  It  has  come  down  to  us  from  the 
days  of  our  grandmothers;  and  while,  in  those  days  it 
may  have  been  justifiable,  in  these  days  of  advancement 
in  dental  science  and  practice,  it  is  so  no  longer,  except 
in  very  rare  and  exceptional  cases. 

"If  the  teeth  really  are  too  far  gone  to  be  saved,  the 
sooner  they  are  out  and  replaced  the  better ;  for,  as  stated 
a  mouth  full  of  decayed  and  decaying  teeth  and  roots  is 
a  menace  not  only  to  health,  but  to  life  itself.  But  let  no 
one  needlessly  sacrifice  his  own  teeth  for  artificial  sub- 
stitutes.   Good  as  they  are  now,  most  necessary  in  their 


PopuLAK  Lectures  on  Dental  Subjects.  37 

place,  and  much  as  many  of  us  owe  to  the  advancement 
in  dentistry  during  these  last  few  years,  they  are  but 
poor  substitutes  at  best. 

^'You  will  be  perfectly  safe  in  trusting  the  judgment 
of  a  good  dentist  in  such  cases.  The  time  has  gone  for- 
ever when  a  dentist  would  extract  a  tooth  that  might  be 
saved,  merely  to  satisfy  the  whim  of  a  patient.  Preser- 
vation and  restoration  of  the  natural  teeth  is  the  proper 
field  for  the  exercise  of  dental  skill ;  and  few  indeed,  and 
daily  growing  beautifully  fewer,  are  the  dentists  who  do 
not  recognize  this  fact,  and  conduct  their  practice 
accordingl3\ 

''Another  cause  of  poor  teeth,  crowded  teeth,  mal- 
formed jaws  and  unbalanced  faces,  with  ill  health  and 
all  the  attendant  train  of  suffering  and  inefficiency,  is 
mouth  breathing,  due  to  a  growth  in  the  nose  called 
adenoids.  This  is  quite  common  in  childhood,  and  is  very 
easily  remedied;  but,  if  neglected,  means  a  weakened, 
impoverished  body,  subject  to  coughs  and  colds,  throat 
and  lung  troubles  leading  on  to  tuberculosis.  Time  will 
not  permit  going  into  this  important  topic'  in  detail,  l)ut 
it  is  the  duty  of  parents  to  watch  their  children,  partic^^ 
larly  while  sleeping;  and,  if  mouth-breathing  is  found  to 
prevail,  to  consult  a  physician  at  once. 

"Sucking  thumbs  and  fingers  in  early  childhood,  the 
use  of  'baby  comforters,'  rubber  nipples  or  other  objects 
held  between  the  teeth,  often  produces  serious  deformi- 
ties of  the  growing  jaws,  and  should  be  avoided  with 
far  greater  assiduity  than  contagion  from  the  simple  dis- 
eases of  childhood.  (****) 

"Just  a  few  words  in  conclusion: 

"Don't  forget  that  the  first  teeth  are  just  as  impor- 
tant while  they  last,  as  the  second  teeth,  if  not  more  so, 
for  the  position,  soundness  and  value  of  the  permanent 
teeth  depend,  very  largely,  upon  the  care  that  the  first 
teeth  receive. 

"Don't  forget  the  number  of  the  first  teeth;  twenty 


38       '  Peactical  Oral  HrGiEisrE. 

in  all,  ten  in  the  upper  jaw,  ten  in  the  lower  jaw,  five  on 
either  side  in  both  jaws. 

"Don't  forget  that  the  sixth  tooth,  the  six-year  molar, 
is  a  permanent  tooth,  and  is  the  largest  and  most  im- 
portant tooth  in  the  entire  set. 

"Don't  forget  that  clean  teeth  do  not  decay;  that  a 
clean  tooth  cannot  decay;  and  therefore,  always  remem- 
her  to  make  ever^^  effort  to  keep  the  teeth  clean — all 
of  them,  on  all  their  surfaces,  all  the  time. 

"Don't  forget  that  clean  teeth,  well  cared  for,  and 
food  well  chewed,  are  essential  to  good  health,  a  sound 
hocl}^  and  a  strong  mind. 

"And  do  not  forget  that  you  are  quite  welcome  to 
ask  any  questions  on  the  subjects  mentioned,  if  every- 
thing that  has  been  said  it  not  perfectly  plain,  simple 
and  clear  to  you." 

Stars  (**)  indicate  the  advisability  of  introducing 
slides  at  points  where  they  appear ;  or  the  slides  may  be 
left  until  after  the  lecture  is  concluded. 

outlijste  lectures. 

Dr.  A.  H.  Stevenson  published  in  Oral  Hygiene,  this 
outline  lecture,  used  by  the  Committee  on  Public  Health 
and  Education  of  the  Second  District  Dental  Society 
of  New  York. 

"In  order  to  obtain  uniform  results,  we  prepared 
lecture  outline  forms  to  cover  our  most  common  tyjDes 
of  audiences.  Three  of  these  I  append.  They  are  merely 
guides  for  the  lecturer,  and  give  him  ample  opportunity 
for  originality,  as  may  be  seen. 

FORM   1.    LECTURE  OUTLINE  FOR  MOTHERS'   CLUBS. 

"The  following  points  seem  to  be  the  ones  that  need 
the  most  emphasis : 

"1.  Show  that  the  responsibility  for  the  general 
healtli  of  tlio  child  depends  mainly  upon  the  mother,  and 


Popular  Lectures  on  Dental  Subjects.  39 

that  she  should  have  somid  ideas  of  how  to  conserve  the 
child's  health. 

''2.  Bring  out  the  influence  that  sound,  clean  teeth 
have  upon  the  general  health  of  the  child. 

''(a)  Show  how  diseased  and  unclean  teeth  play  a 
large  part  in  the  causation  of  disease.  That  the  main 
method  of  infection  in  the  following  diseases  is  the  dis- 
charges of  the  mouth:  Tuberculosis,  pneumonia,  influ- 
enza, la  grii^pe,  diphtheria,  measles,  scarlet  fever, 
mumps,  etc. 

''(b)  Show  that  lack  of  or  decay  of  the  teeth  cause 
mal-nutrition,  mouth-breathing,  adenoids. 

''(c)  Show  how  the  pain  of  diseased  teeth  may  be 
reflected  and  cause  disturbances  in  the  eye,  ear,  face, 
neck,  head  and  other  parts  of  the  body. 

"3.  Show  how  the  temporary  teeth  develop  and  then 
the  permanent  ones.     (Use  charts.) 

"4.  Show  the  importance  of  preserving  both. 

"5.  Lay  particular  emphasis  on  the  six-year  molar. 

"6.  Conclude  with  general  mouth  hygiene  as  follows: 

''Articles  required:  Brush — Size,  shape  and  bristles. 
Floss — How  to  use.     Dentifrice — Warning  and  advice. 

"Method  of  brushing.  Time — Every  time  the  teeth 
are  unclean.    Tell  something  about  the  removal  of  tartar. 

"X.  B. — Use  simple  language  and  avoid  technical 
terms.  At  the  close  of  the  talk  invite  the  mothers  to  ask 
questions.  Eemember  as  many  of  the  questions  as  pos- 
sible and  mail  them  with  any  suggestions  to  the 
committee. 

"form  2.    OUTLINE  OF  TWENTY-FIVE  MINUTE 
TALK  TO   CHILDREN. 

"1.  (For  boys.)  Show  how  success  in  sports  and  life 
depends  upon  good  health. 

"(For  girls.)  Show  how  success  in  singing,  reciting 
or  any  public  appearance  depends  upon  good  health. 

"Show  that  good  health  is  impossible  without  clean 
mouths  and  good  teeth. 


40  Peactical  Oeal  Hygiene. 

"2.  Explain  the  relation  of  sound,  clean,  temporary 
teetli  to  health.  Explain  the  relation  of  sound,  clean, 
permanent  teeth  to  strength,  endurance,  grace,  beauty 
and  class-standing. 

"3.  State  briefly  how  decay  is  produced  and  it  ex- 
tends, using  illustrations  if  possible. 

^'4.  Emphasize  the  importance  of  ]3reserving  the 
temporary  teeth,  and  the  six  year  molar. 

"Introduce  the  phrase  'A  clean  tooth  never  decays.' 

"Have  children  repeat  it  in  unison. 

"5.  Conclude  with  general  mouth  hygiene  as  follows: 

"Articles  required:  Brush — Size  and  shape,  bristles. 
Floss — How  to  use.    Dentifrice — Warning  and  advice. 

"Method  of  brushing.  Time — Every  time  the  teeth 
are  unclean.  Tell  something  about  the  removal  of  tartar. 
jST.  B. — ^As  above. 

"rOEM  3.    LECTUEE  OUTLINE  FOE  NUESES    (aND  PHYSICIANS.) 

"Preface  with  remarks  showing  the  sphere  of  pre- 
ventative medicine,  and  as  a  part  of  same  the  impor- 
tance of  the  oral  hygiene  crusade;  indicating  its  scope 
value  and  application.  Emphasize  the  necessity  of  the 
co-operation  of  the  nurses  (and  physicians)  to  bring 
about  its  aim. 

"The  following  points  seem  to  be  the  ones  that  need 
the  most  emphasis : 

"1.  Show  how  unclean  mouths  are  ideal  mediums  for 
the  proliferation  of  bacteria.  Indicate  the  following  as 
diseases  whose  main  means  of  infection  is  the  discharges 
of  the  mouth:  Tuberculosis,  pneumonia,  influenza,  la 
grippe,  diphtheria,  measles,  mumps,  etc.  (Quote  authori- 
ties, as  per  Form  3a.) 

"Show  how  lack  of  or  impairment  of  the  teeth  cause 
malnutrition,  mouth  breathing,  adenoids. 

"2.  Give  brief  histology  and  development  of  the 
teeth,  temporary  and  permanent,  showing  how  calcifica- 
tion proceeds  and  dietetic  influences.    (Use  charts.) 


PopuLAE  Lectures  ox  Dental  Subjects.  41 

"3.  Show  prevalence  and  nature  of  dental  caries  as  a 
disease  itself,  and  conditions  favorable  for  its  inception 
and  increase.  Show  how  reflexly  disorders  of  the  eye, 
ear  and  brain  may  result. 

''4.  Give  general  mouth  hygiene  for  normal  condi- 
tions indicating: 

''Articles  required:  Brush — Size  and  shape.  Floss — 
How  to  use.    Dentifrice — Warning  and  advice. 

"Method  of  brushing.  Time — Every  time  the  teeth 
are  unclean.  Mention  the  formation  and  removal  of 
tartar. 

"d.  Give  the  application  of  the  hygiene  by  nurses, 
emphasizing : 

"(a)   The  preparation  of  patients  for  operations. 

"  (b)  The  care  of  the  mouth  during  pregnancy.  (Eead 
article  in  Vol.  I,  No.  2,  Oral  Hygiene.) 

"  (c)  The  care  of  the  mouths  of  children. 

"(d)  The  care  of  the  mouths  of  invalids  and  con- 
valescents. 

"6.  Conclude  with  the  importance  of  strict  oral  clean- 
liness on  the  part  of  the  nurses,  as  a  safegiiard  against 
infection  for  themselves  and  for  those  for  whom  they 
care. 

"N.B.— As  above. 

"form   3a.       lecture  OUTLIiSTE  FOE   XUESES  AXD  PHYSICLAXS. 

NOTES. 

"  'From  a  hygienic  standpoint  the  secretions  of  the 
mouth  constitute  the  chief,  if  not  the  only,  source  of 
respiratory  infection.' — Dr.  TVadsworth  of  the  ]\[edical 
Commission  for  the  investigation  of  Acute  Eespiratory 
Diseases,  N.  Y.  Dept.  Health. 

"  'Each  patient  should  be  furnished  with  a  new  tooth- 
brush and  a  bottle  of  antiseptic  mouth  wash,  and  the 
nurse  instructed  to  cleanse  the  mouth  every  2  or  3  hours, 
prior  to  a  surgical  operation.' — ^Foynahan. 


42  Peactic.\l  Oeal  Hygiexe. 

a  'Three  patients  (two  men,  one  woman)  died  from 
tuberculosis.  In  eacli  of  these  three  cases  the  contribu- 
ting cause  was  a  decayed  or  impacted  third  molar  tooth. ' 
— M.  Dubois,  Chief  of  Clinics  at  the  Ecole  Odonto,  Tech- 
nique. Paris,  France,  from  Mevnue  Generale  de  L'Art 
Dentaire. 

"  'Several  cases  of  tonsilar  inflammation  are  caused 
by  the  focus  of  infection  in  the  mucous  membrane  near 
a  decayed  third  molar  tooth.  Also  persistent  throat 
inflammation  and  tonsilitis  is  caused  by  the  infection 
from  decayed  or  diseased  teeth.' — F.  Le  Maire,  Paris, 
France,  in  the  Odontologue. 

'•  'Many  cases  of  chronic  lacuna  tonsilitis  have  arisen 
from,  and  are  continued  because  of  neglected  teeth  and 
gums.  Chronic  laryngeal  catarrhs  ma}-  be  continued  by, 
if  not  originated  by,  diseased  conditions  of  the  teeth  and 
gTims.' — Wyatt  Wingrave,  M.  D.,  Durham,  Eng.,  in  the 
London  Lancet. 

"  'Measles,  German  measles,  chicken-pox,  whooping 
cough,  mumps,  scarlet  fever,  or  scarletina,  diphtheria, 
influenza  and  small-pox,  all  have  for  their  method  of  in- 
fection either  the  discharges  of  the  mouth,  nose,  or  par- 
ticles of  the  skin,  and  the  most  fertile  soil  and  the  most 
prolific  breeding  ground;  and  the  best  harbor  and  the 
never  failing  spring  for  the  germs  of  all  these  diseases 
are  filthy  and  decayed  teeth.' — A  Brown  Ritchie,  medi- 
cal officer  to  the  Education  Committee  of  the  City  of 
Manchester,  Eng.,  in  Allen's  Civics  and  Health. 

"  'Out  of  684  sarcomas  in  different  regions  of  the 
body,  309  of  these  were  either  on  the  lower  lip,  upper 
lip,  tongue,  mucus  membrane  of  the  soft  and  hard  palate. 
One  very  frequent  cause  of  these  maligTiant  tumors  is 
the  constant  irritation  of  a  sharp  edge  of  a  decayed 
tooth.'— Woods  Hutchinson,  A.M.,  M.  D. 

"  'Ninety  per  cent,  of  all  the  destructive  diseases  of 
the  upper  and  lower  jaw  bones  have  for  their  chief  and 
almost  their  sole  cause,  dental  alveola  abscesses  (and  90 
per  cent,  of  the  dental  alveola  abscesses  are  caused  by 


PopuLAK  Lectures  ox  Dextal  Subjects.  43 

decayed  teeth).  Persistent  lieadaclies  and  general  reduc- 
tion in  health  are  frequently  caused  by  insiduous  aveola 
abscesses.' — Stewart  L.  McCurdy,  M.  D.  (Section  of 
Stomatology,  A.M. A.).  The  value  of  our  most  recent 
efforts  in  the  training  schools  for  nurses  is  self-evident. 
These  nurses,  heretofore  uninstructed  on  the  subject,  be- 
come active  agents  of  the  campaign. 

''OUTLIISrE   OF   SHORT  TALK   TO  KINDERGARTEIsr   CHILDREN. 

"Open  talk  with  either  story  or  demonstration  to 
attract  attention,  and  then  proceed  with  the  following: 

"1.  Describe  graphically  the  doorway  and  vestibule 
of  a  house,  and  the  effect  on  the  interior  of  that  house, 
be  it  ever  so  neat  and  clean,  of  a  dirty  entrance  with 
children  passing  in. 

"2.  Show  the  analogy  of  the  mouth  as  the  doorway 
and  vestibule  of  the  body,  and  the  effect  on  the  interior 
of  the  body  of  an  unclean  mouth  with  food  passing 
through  and  carr^dng  filth  into  the  stomach. 

"Eesults:  Disease  and  illness;  loss  of  play  and 
school. 

"3.  Ask  how  many  children  washed  their  faces  before 
coming  to  school.  (Usually  unanimous.)  Then  show  the 
importance  of  cleaning  the  'inside  of  the  face,'  in  order 
to  be  clean  and  well. 

"4:.  Very  briefly,  with  a  large  model,  if  possible,  show 
the  alignment  of  the  teeth.  Tell  the  necessity  of  keeping 
them  clean  to  prevent  'holes'  and  pain. 

"5.  Conclude  with  simple  mouth  hygiene,  demonstrat- 
ing with  giant  tooth-brush  on  model,  and  emphasize  the 
frequency  of  this  operation  and  the  use  of  a  dentifrice." 


CHAPTER     IV. 

POPULAR  LECTURES— CONTINUED. 

ax  illusteated  lectuee,  zaeboxjgh. lectuee  eoe  school 

childeek:  eeom  foueth  to  eighth  geade,  coeley. 
lectuee  eoe  school  childeen",  hunt. 

If  it  is  convenient  to  obtain  the  lantern  and  proper 
slides,  the  following  lecture  hy  Dr.  L.  L.  Zarbongh,  can  be 
used  to  advantage.  The  cuts  suggested  are  easily  made 
and  show  to  good  advantage.  While  the  article  was 
written  on  the  subject  of  "Moving  Pictures  in  Dentistry," 
I  have  moved  it  around  a  little  so  that  it  will  fit  the 
subject  of  "Outline  Lectures  in  Dentistry." 

"Open  with  a  home  scene,  showing  family  group, 
children  playing  or  reading,  mother  sewing  or  darning, 
father  reading  the  evening  paper.  He  reads  an  article, 
^The  time  to  begin  to  care  for  teeth  is  in  childhood,'  etc. 
Father  calls  mother's  attention  to  the  article,  which  is 
then  shown  on  the  screen.  They  then  look  at  the  child- 
ren's teeth,  and  decide  then  and  there  to  instruct  the 
children  in  the  care  of  their  teeth, 

"Next  is  shown  a  dental  nurse  or  dentist  instructing 
the  children  in  the  proper  manner  of  caring  for  the  teeth, 
the  use  of  dental  floss,  the  folly  of  blunt  wood  tooth-picks,, 
etc.,  the  correct  method  of  brushing  the  teeth,  etc. 

"Then  follow  with  a  short,  'cute'  picture  of  'ihe  baby'' 
brushing  his  teeth,  as  the  dentist  has  directed. 

"Other  subjects  will  be  the  interior  of  a  school-room,, 
showing  the  examination  of  school  children's  teeth,  show- 
ing that  the  instruments  are  sterilized  after  each  child — a 
near  view  of  just  how  it  is  done;  also  showing  a  near 
view  of  20  boys  and  girls,  showing  only  the  mouth  and 
teeth,  and  pointing  out  the  decayed  teeth  in  each  mouth 
and  other  defects  as  they  exist. 

"Show  the  number  of  percentage  of  20  children  need- 
ing dental  services.     It  should  be  vivid  and  convincing, 


Popular  Lectures  oi^  Dental,  Subjects.  45 

and  will  go  a  loug  way  towards  removing  the  prejudice 
existing  in  tlie  minds  of  many  members  of  school  boards 
and  teachers  against  it.  This  part  of  the  lecture  will 
awaken  such  an  interest  on  the  part  of  the  public*  that 
they  will  demand  the  examination  of  school  children's 
teeth— the  very  thing  we  are  striving  for;  and  the  best 
way  to  get  into  the  schools  is  to  create  an  interest  in  the 
public  mind,  which  will  soon  grow  into  a  demand. 

"Then  show  a  near  view  of  an  unhealthy  mouth,  loose 
teeth,  tartar,  pus,  etc.  Move  the  loose  teeth  with  an 
instrument;  show  the  ruin  that  neglect  will  cause  in  a 
mouth;  then  show  this  same  mouth  as  it  will  appear  a 
short  time  later,  unless  cared  for,  as  barren  of  teeth  as 
the  mouth  of  a  new  baby. 

"Next  show  the  progress  of  decay,  by  picture  or  black- 
board illustration,  in  a  tooth  from  the  ver}'  start  until 
the  death  of  the  dental  pulp,  the  breaking  down  of  the 
enamel,  etc.  This  will  be  done  mechanically;  the  decay 
will  be  seen  moving  towards  the  pulp;  the  period  or  time 
at  which  the  tooth  begins  to  ache  will  be  pointed  out, 
etc.  Some  of  the  text,  no  doubt,  will  be  along  the  follow- 
ing lines : 

"Fig.  1.  Uncared  for  teeth,  showing  food  particles, 
which,  fermenting,  form  acid. 

"Fig.  2.  Showing  the  acid  attacking  the  lime  in  the 
enamel  rods. 

"Fig.  3.  Showing  decay  attacking  dentine. 

"Fig.  4.  Showing  further  progress  of  decay;  tootli 
begins  to  ache. 

"Fig.  5.  Showing  undermining  and  breaking  down  of 
enamel  walls,  exposing  largo  cavity  whicli  has  been  form- 
ing, unsuspected,  for  months. 

"Fig.  6.  Showing  death  of  dental  pulp,  formation  of 
gas,  pus,  etc.,  in  jDulp  chamber;  escape  of  gas  at  apex, 
swelling,  abscess,  etc. 

"It  has  been  suggested  that  inasmuch  as  we  show  tlie 
death  of  the  pulp,  for  a  change,  and  to  give  the  people 
a  chance  to  relax  a  little,  we  show  the  funeral  of  a  dental 


46 


Peactical  Oeal  Hygiene. 


SHOW/NO  FOOD  PARTICLES,  WHICH  FERMENT/NGMMAUO  Jao  /imcH/NC  THE  LIME  IN  THE  ENAMEL  rods 


SHOWING  DEC  A  YATTA  CK/NG  DENTINE  /i/rflierPro^rej^of Decay  -  Tooth  de£ms  ToAc/?e_ 


UNDERMINING  AND  BREAKING  DOWN  "^^  EMMEl  MllS  OEATNOEDE/mL  Pl/LP  OR  NERVT 


Exposing  Lar^eCdnl/ which hai  been  forminjiUnsuspeckd,  lor  Months,    fbrmafion  oT  PUS snd G^S  in  Pu/pLhdmber 

Fig.  4.   Showing  the  Various  Steps  in  Tooth  Decay. 


PopuLAK  Lectures  on  Dental  Subjects.  47 

pulp,  witli  the  owner  of  tlie  tootli  as  chief  mourner. 
Worked  up  properly  it  would  be  very  funny  and  make 
the  people  in  the  theatre  wonder  just  how  long  they  will 
dare  to  wait  before  they,  too,  will  have  a  funeral  of  their 
own. 


Showing'  growth  and  multiplicafion  of 

Fig.  5.     Showing  the  Steps  in   Tooth  Decay. 

^ '  Fig.  7.  A  badly  decayed  molar,  showing  the  growth 
of  bacteria  in  such  a  tootli  in  24  hours.  The  multiplica- 
tion of  germs  also  will  be  shown  in  motion  and  will  teach 
such  a  lesson  that  anyone  seeing  it,  who  has  a  deeayed 
tooth,  will  not  go  to  bed  without  making  some  elTort  to 
clean  it  up.  When  we  consider  the  appalling  rapidity 
Avitli  which  bacteria  multiply  we  can  realize  how  inter- 
esting this  picture  is  sure  to  be.  According  to  Conn, 
professor  of  biology  at  Wesleyan  University,  *^it  is  the 
power  of  multiplication  by  division  tliat  manes  bacteria 
so  significant.  This  power  of  growth  is  almost  incredible. 
Some  species  divide  every  30  minutes,  or  even  less.  At 
this  rate  each  bacterium  would  produce,  in  a  single  day, 
more  than  16,500,000  descendants;  in  two  davs  about 
281,500,000,000,  or  about  one  solid  pint.  At  tlie  end  of 
the  third  day,  unless  checked,  the  product  of  one  original 
bacterium  would   weigh   about   16,000,000   pounds.     Of 


48  Peactical  Oeal  Hygiejste. 

course,  this  growtli  is  on\j  theoretical,  as  iiucler  no  con- 
ceivable bodily  conditions  could  it  go  on  unchecked." 

"Tell  about  a  boy  ivho  ivoulcl  not  clean  Ms  teeth;  show 
him  going  to  bed  with  the  toothache  (making  a  striking- 
example  of  him),  show  the  usual  fuss,  hot  water  bottles, 
etc.;  then  show  a  dream  that  he  has  while  in  bed;  he 
dreams  of  a  trip  to  the  dentist,  as  he  supposed  it  would 
be.  Very  funny,  of  course,  yet  so  arranged  as  not  to 
bring  criticism  on  the  profession  or  detract  from  the  real 
purpose  of  the  lecture.  Then  after  the  night-mare,  a 
trip  to  the  dentist  as  it  really  ivas;  show  him  treated 
kindly  and  relieved  of  his  suffering,  etc.  State  that  fear 
and  ignorance  cause  more  pain  and  keep  more  people 
from  visiting  the  dentist  than  any  other  one  thing. 

"Next  tell  the  good  resulting  from  care  of  the  teeth; 
show  a  healthy  mouth  from  childhood  to  old  age;  show 
teeth  without  a  blemish,  every  one  sound,  without  even 
a  filling.  This,  too,  will  teach  a  great  lesson  and  make 
a  lasting  impression," 

LECTUKE  FOR  SCHOOL  CHILDREjST  FEOM  FOURTH  TO      , 
EIGHTH   GRADE. 

Compiled  by  J.  P.  Corley,  M.  D.,  D.  D.  S.,   Sewaiiee,   Tenn. 
Star   (■■■■)   indicates  the  advisability  of  introducing  slides  at  points 
Avhere  they  ajipear;  or  the  slides  may  be  left  until  after  the  lecture  is 
concluded. 

We  have  a  great  many  good  things  in  this  life,  but 
the  greatest  possession  of  all  is  good  health.  Health  is 
more  important  to  children  than  to  grown  up  people,  be- 
cause if  one  is  not  well  while  he  is  growing,  he  will  not 
have  a  strong  vigorous  body  when  he  becomes  grown  up, 
and  he  will  be  more  apt  to  have  all  kinds  of  diseases 
during  the  rest  of  his  life. 

Clean,  wholesome,  well-prepared  food  has  more  to  do 
with  the  health  of  a  child  than  any  other  one  thing.  If 
food  is  clean  and  wholesome,  but  is  taken  through  a 
mouth  which  is  unclean  and  unwholesome,  it  will  not  be 
clean  and  wholesome  when  it  gees  into  the  stomach. 


PopiTLAE  Lectures  ox  Dextal  Subjects.  49 

(*)  This  first  picture  shows  a  man  with  his  front  cut 
away,  sliowing  the  canal  through  which  the  food  passes 
into  and  out  of  the  body.  The  large  hole  which  we  see 
at  the  top  of  the  canal  is  the  mouth.  If  the  food  is  clean 
and  the  mouth  is  clean  our  stomachs  will  get  clean  food, 
but  if  the  mouth  is  filthy,  the  food  will  surely  be  made 
filthy  before  it  is  swallowed.  A  great  many  germs,  such 
as  diphtheria,  scarlet  fever,  typhoid  fever,  and  tubercu- 
losis, are  frequently  found  in  mouths  which  are  habitually 
unclean  and  full  of  decayed  teeth. 

Some  times,  after  a  person  gets  well  of  a  disease,  he 
will  carry  the  germs  of  this  disease  in  his  decayed  teeth, 
and  by  spitting,  and  various  other  ways,  give  the  disease 
to  other  people. 

(*)  This  is  a  toothless  pair.  Old  ''Mammy"  has  lost 
all  her  teeth  and  the  "baby  child"  has  not  gotten  hers; 
at  least,  we  can't  see  them,  but  if  she  should  scald  her 
little  mouth  bad  enough  for  the  gums  to  come  off,  we 
would  see  a  row  of  sacks  just  under  where  the  teeth  will 
peep  through  when  they  come  into  the  mouth. 

(*)  Just  inside  of  this  row  of  sacks  there  is  another 
row  of  smaller  sacks.  If  we  should  slit  open  one  of  these 
sacks  what  do  you  think  we  would  find?  The  top  of  a 
beautiful  little  tooth  like  a  bulb,  which  in  the  spring  time 
peeps  up  through  the  ground  and  opens  into  a  beautiful 
flower.  This  tooth  is  pretty  and  clean  and  hasn't  a  de- 
cayed spot  about  it,  and  if  it  is  kept  clean  as  long  as  it 
remains  in  the  mouth,  it  will  never  decay.  The  baby 
ought  not  to  suck  her  thumb  or  keep  a  pacifier  in  her 
mouth  all  day,  because  this  will  mash  these  little  sacks 
out  of  place  and  will  make  her  teeth  crooked.  (*)  It  will 
also  change  the  shape  of  the  soft  bones  of  the  front  of 
the  face  and  make  her  little  nose  turn  up  like  this.(*). 
So,  if  you  don't  want  the  baby's  nose  to  turn  up,  you  had 
better  tell  your  mother  not  to  let  her  suck  her  thumb. 

(*)  The  picture  on  the  left  shows  the  upper  part  of 
the  mouth  of  a  child  two  and  a  half  or  three  years  old, 
with  all  the  first  set  of  teetli  in  jilace.    You  see  that  they 


50  Peactical  Oral  Hygiene. 

are  all  sound  and  regularlj'  arranged.  Tliere  is  never  a 
crooked  or  misplaced  tooth  in  the  first  set,  but  there  are 
frequently  mis-placed  teeth  in  the  second  set.  The  most 
common  cause  is  that  the  mouth  and  jaws  have  not  grown 
large  enough  for  the  second  set.  Chewing  is  w^hat  makes 
the  jaws  grow,  so  if  your  teeth  are  crowded  and  crooked, 
it  is  because  you  didn't  chew  with  your  first  set.  Some- 
times, as  we  will  see  in  a  moment,  other  things  keep  the 
jaws  from  growing  and  mis-place  the  tooth,  but  the  lack 
of  chewing  is  the  main  cause.  The  picture  on  the  right 
shows  the  same  case  at  about  six  years  old.  It  has 
another  group  of  teeth.  They  belong  to  the  second  or 
permanent  set.  If  you  lose  these  you  will  never  get 
others  to  take  their  places.  They  are  called  the  sixth- 
year  molars,  and  are  the  largest  and  most  useful  teeth 
in  the  mouth.  They  are  more  frequently  decayed  than 
any  others  for  the  reason  that  boys  and  girls  at  six  to 
nine  years  don't  usuall}"  keep  their  teeth  clean.  The 
mother  usually  thinks  these  teeth  are  part  of  the  first 
set,  and  thinks  it  does  not  make  much  difference  if  they 
are  lost,  but  we  will  have  more  to  say  about  these  teeth 
in  a  moment.  You  will  notice  that  one  of  the  front  teeth 
is  missing.  Do  you  suppose  the  dentist  had  to  pull  this 
tooth  because  it  ached?    No. 

(*)  It  just  dropped  out  and  ''didn't  hurt  a  bit."  I 
am  going  to  show  you  why  it  dropped  out. 

(*)  In  this  picture  the  bone  has  been  cut  away  from 
the  roots  of  the  temporary  teeth  and  we  find  that  just 
above  each  little  temporary  tooth  there  is  a  big  perma- 
nent one.  The  permanent  tooth  comes  down  upon  the 
end  of  the  temporary  tooth  and  nibbles  it  off  as  a  mouse 
nibbles  cheese,  so  that  by  the  time  the  permanent  tooth 
gets  ready  to  come  into  the  mouth  the  temporary  tooth 
has  lost  its  root  and  drops  out.  But  I  am  going  to  tell 
you  something  which  I  want  3^ou  to  tell  your  mothers.  If 
the  temporary  tooth  is  allowed  to  decay  until  it  aches, 
the  permanent  one  will  stop  nibbling  and  you  will  have 
to  0:0  to  i]\o  dentist  and  have  him  grind  it  down  to  the 


PopuLAK  Lectures  ox  Dental  Subjects.  51 

gums  so  that  the  new  tooth  can  pnsh  it  like  yon  would 
drive  one  nail  out  with  another.  This  is  one  reason  why 
the  temporary  teeth  should  be  kept  clean  and  free  from 
decay.  Another  reason  is  that  you  can't  chew  so  well 
if  your  temporary  teeth  are  decayed.  Your  jaws  will  not 
grow  and  be  large  enough  for  the  permanent  teeth,  and 
you  will  suffer  from  indigestion  and  its  consequences. 
It  will  also  be  impossible  to  keep  3^our  mouth  free  from 
germs  and  the  new  teeth  will  decay  as  soon  as  they 
come  in. 

(*)  When  one  is  four  years  old  the  teeth  are  close 
together,  but  if  the  jaws  are  properly  used  in  chewing, 
they  begin  to  separate  as  the  jaws  grow,  so  that  by  the 
time  one  is  six  years  old,  the  teeth  do  not  stand  apart 
as  they  do  in  this  picture. 

(*)  The  dentist  should  put  in  a  little  appliance  to 
spread  the  arch,  otherwise  the  |)ermanent  teeth  will  be 
crowded. 

(*)  This  man  didn't  chew  his  food  when  he  was  a  boy. 
I  guess  he  just  gobbled  it  up  with  both  hands  like  this — 
(Illustration),  so  his  mouth  didn't  grow  and  his  teeth 
were  all  awry.  His  mouth  and  face  didn't  grow  either, 
so  he  had  a  big  head  and  a  little  pinched  face. 

(*)  This  man  chewed  his  food  when  he  was  a  boy, 
and  when  he  grew  to  be  sevent^^-five  years  old,  he  had  all 
his  teeth  and  was  a  good-looking,  hearty  old  man.  I 
guess  he  just  chewed  and  chewed  and  chewed,  until  the 
food  just  swallowed  itself.  You  needn't  bother  about 
swallowing  your  food.  After  it  has  been  sufficiently 
ground,  it  will  slip  down  without  any  effort. 

(*)  This  is  the  lower  set,  and  they  are  just  as  fine 
as  the  upper.  Those  dark  lines  which  you  see  marking 
the  tops  of  the  back  tooth  are  grooves,  which  divide  the 
top  or  grinding  surface  of  the  tooth  into  points  and  de- 
pressions. By  this  arrangement  the  free  surface  of  the 
tooth  is  increased  and  its  unevenliness  makes  it  a  much 
more  efficient  grinder, 

(*')  This  is  the  same  case  with  the  teeth  brought  to- 


52  Peagtical  Oeal,  Hygiene. 

getlier,  Xotice  liow  beautifully  they  fit,  and  also  that  each 
upper  tooth  touches  two  lower  ones.  Which  one  of  these 
teeth  could  one  atford  to  lose? 

If  you  should  saw  through  a  front  tooth  and  through 
the  gum  and  bone  to  the  end  of  the  root,  you  would  find 
that  the  tooth  is  made  up  of  four  different  substances. 
The  one  which  covers  the  top  is  enamel,  and  it  is  the 
hardest  organic  substance  in  the  world  except  diamond. 
The  next  substance  which  makes  up  the  bulk  of  the  tooth 
is  dentine,  which  is  not  so  hard  and  wears  and  decays 
more  rapidly.  Encasing  the  root  is  a  still  softer  sub- 
stance called  cementum.  Occupying  a  canal  in  the  center 
of  the  tooth  is  the  pulp,  which  is  composed  of  blood  ves- 
sels and  nerves.  When  decay  makes  a  hole  through  the 
enamel  and  dentine  into  this  pulp,  the  tooth  begins  to 
ache.  Surrounding  the  root  and  attaching  it  to  the  gum 
and  bone,  is  a  thin  membrane — the  peri-cementum.  If 
you  allow  tartar  to  accumulate  on  the  teeth  and  remain 
for  a  long  time,  it  will  destroy  this  membrane  and  the 
tooth  will  loosen  and  drop  out.  Teeth  are  lost  mainly 
in  two  ways — by  decay,  which  destroys  their  crowns,  and 
by  disease  of  the  gums  and  destruction  of  the  peri- 
cementum. Both  of  these  causes  can  be  prevented  by 
yourself,  and  I  am  going  to  tell  you  how  you  may  do  it. 
We  will  first  tell  you  how  to  avoid  diseases  of  the  gums. 

(*)  If  you  will  examine  your  teeth  when  you  first  get 
up  in  the  morning,  you  will  find  them  covered  with  a 
thin,  soft,  yellowish  deposit,  which  you  can  scrape  off 
with  a  tooth  pick  and  examine.  It  looks  like  cream,  but 
it  doesn't  taste  like  cream  and  it  doesn't  smell  like  cream. 
It  is  composed  of  epithelial  cells,  which  shed  from  the 
lining  of  the  mouth,  mucus  and  microscopic  granules  of 
lime  from  the  saliva,  and  if  the  mouth  has  not  been 
cleansed  of  food  before  retiring  it  will  contain  decayed 
]>articles  of  food.  If  you  do  not  brush  this  deposit  off 
carefully  before  eating,  the  food  will  strij^  it  down  over 
the  tooth  and  pack  a  little  ring  of  it  under  the  free  mar- 
gin of  the  gum.     If  it  is  allowed  to  remain  there  for  a 


Popular  Lectuees  on  Dextal  Subjects.  53 

very  long  time,  it  becomes  so  hard  that  only  the  dentist 
can  remove  it,  and  it  will  cause  the  gums  to  inflame.  A 
little  is  added  to  it  every  day,  and  by  and  by  the  entire 
root  will  be  covered  and  the  gum  destroyed. 

(*)  This  is  practically  the  same  thing  which  causes 
disease  of  the  gums. 

(*')  See  this  deposit  on  the  side  of  the  tooth  on  the 
right.  In  the  picture  on  the  left,  this  deposit  has  been 
removed,  showing  how  much  of  the  membrane  has  been 
destroyed. 

(*)  The  tongue  side  of  the  lower  front  teeth  is  the 
most  favorite  place  in  the  mouth  for  the  accumulation 
of  this  deposit,  partly  for  the  reason  that  a  great  quan- 
tity of  saliva  is  poured  out  at  this  point,  but  principally 
because  these  surfaces  are  not  properly  brushed. 

(*)  This  shows  a  deposit  on  the  cheek  side  of  the 
upper  back  teeth,  which  is  also  a  surface  not  usually 
reached  with  the  brush. 

(*)  After  the  gums  have  gotten  as  bad  as  this,  there 
is  no  way  to  save  the  teeth,  and  they  will  soon  be  drop- 
ping out.  Eemember  that  this  disease  of  the  gums  can 
be  prevented  b}'^  thoroughly  brushing  the  teeth  twice  a 
day.  We  will  show  3^ou  in  a  moment  how  to  brush  them 
thoroughly.  Let  us  now  take  up  decay,  which  is  the  other 
great  disease  of  the  teeth,  and  we  will  then  show  you 
how  both  may  be  prevented. 

(*)  If  you  will  examine  the  tojis  of  the  l^ack  teeth 
immediately  after  eating  you  will  see  that  the  little 
grooves  which  mark  their  surfaces,  are  filled  with  food. 
At  first  the  food  is  granular  and  may  be  removed  easily. 
Usually  a  vigorous  rinsing  of  the  mouth  is  all  that  is 
necessary,  but  if  it  is  not  removed  at  once  it  begins  to 
ferment  and  develops  a  muculaginous  condition,  which 
makes  its  removal  much  more  difficult.  During  the  pro- 
cess of  fermentation,  an  acid  is  produced  which  dis- 
solves the  enamel.  This  is  about  the  only  thing  which 
causes  teeth  to  decay.     Hence,  if  no  food  be  allowed  to 


54  ^        Practical  Oral  Hygieate. 

remain  in  tlie  mouth  mitil  fermentation  occnrs,  there  will 
be  no  tooth  decay. 

(*)  In  tooth  No.  1,  the  decay  is  very  small.  The  point 
where  it  made  its  way  through  the  enamel  is  scarcely 
larger  than  the  head  of  a  pin,  but  3'on  can  see  that  it  is. 
much  larger  in  the  dentine  than  it  is  in  the  enamel.  This 
is  because  the  dentine  decays  more  rapidly  than  the 
enamel.  A  cavity  can  be  prepared  for  filling  at  this  stage 
with  little  time,  joain  and  expense,  as  shown  in  fig.  No.  2, 
but  if  you  wait  until  the  cavity  becomes  large,  as  is  shown 
in  No.  3,  it  requires  much  more  time,  hurts  much  worse, 
costs  a  great  deal  more  and  does  not  last  so  long.  Hence, 
the  teeth  should  be  examined  several  times  a  year  by  a 
dentist,  and  every  decayed  spot  which  is  too  deep  to 
dress  out,  filled  while  it  is  small.  Tooth  deca}^  never  gets 
well,  but  always  gets  worse,  so  the  sooner  the  cavity  is 
filled,  the  better. 

(*)  These  pictures  show  the  historj^  of  a  tooth  from 
the  beginning  of  decay  until  the  development  of  an 
abscess  and  the  establishment  of  a  fistula,  commonly 
called  a  gum  boil.  (Go  more  or  less  into  the  details  of 
the  ditferent  steps  of  the  process  and  the  changes  which 
take  place  in  the  pulp,  giving  a  few  facts  pertaining  to 
the  proper  treatment  of  such  cases  with  special  emphasis 
on  the  importance  of  retaining  the  tooth.) 

If  the  residue  of  food  is  not  removed  after  each  meal 
and  the  last  thing  eaten  something  soft  and  sticky,  as  is 
too  frequently  the  case,  the  mouth  will  sooner  or  later 
present  the  appearance  of  this  one  with  cavities  between 
the  teeth  and  in  the  depressions  in  the  tops  of  the  back 
teeth,  and  unless  dental  attention  is  given  this  case,  the 
teeth  will  soon  be  aching  and  breaking  down  like  the 
ones  in  the  next  slide. 

(*)  Some  of  these  teeth  have  broken  so  badly  that 
they  are  worthless  as  grinders,  they  are  liable  to  ache  at 
any  time  and  develop  abscesses,  they  are  so  many  gar- 
bage cans  infesting  the  saliva  which  is  constantly  being 
swalloAved   and  contaminating  all    food   and   drink.     A 


Popular  Lectures  ox  Dextau  Subjects.  55 

month  in  the  condition  of  this  cannot  he  othAvvrise  than 
filthy  and  a  great  menace  to  the  health  of  its  possessor 
and  its  neighbors. 

(*)  This  is  a  side  view  of  the  same  case  with  the  teetli 
bronght  together  as  in  chewing.  It  shows  what  an  enor- 
mons  amount  of  grinding  surface  is  lost.  But  even 
though  your  teeth  are  as  badly  broken  down  as  these, 
you  should  not  pull  them  out.  Their  tops  can  be  restored 
by  fillings,  inlays,  and  crowns,  so  long  as  the  roots  are 
strong,  which  is  immensely  better  than  artificial  substi- 
tutes. Some  grown  up  people  may  tell  you  that  it  makes 
little  difference  if  you  lose  this  first  permanent  jaw  tooth 
before  you  are  fifteen  years  old,  because  the  space  will 
soon  be  filled  up  by  the  next  tooth  coming  forwai'd.  AVell, 
the  space  does  fill  up.  More's  the  pity.  It  would  be 
better  for  you  if  the  space  didn't  close  up.  Let  me  show 
you  how  the  space  closes  up. 

(*)  The  teeth  behind  the  space  lean  forward,  and 
lean  forward,  and  lean  forward,  and  the  tooth  in  front 
of  the  space  leans  backward  and  leans  backward,  until 
their  top  corners  almost  or  quite  touch,  thus  closing  the 
space  at  the  top,  but  not  at  the  bottom. 

In  thus  leaning  toward  each  other,  their  touching 
surfaces  are  so  turned  that  they  fail  to  touch  the  upper 
teeth  in  chewing  and  their  fit  in  is  entirely  sjioiled.  The 
bone  buckles  as  the  teeth  lean,  so  instead  of  losing  the 
use  merely  of  the  tooth  extracted,  you  also  lose  one-half 
to  two-thirds  of  the  grinding  efficiency  of  all  the  grind- 
ing teeth  on  that  side  of  the  mouth.  But  this  is  only 
one  of  the  many  consequences  of  losing  this  tooth  in 
early  life.  It  causes  a  general  warping  of  the  bones  of 
the  nose  and  front  face,  which  often  helps  to  produce 
catarrh  and  a  number  of  other  diseases  which  we  have 
not  time  to  mention.  It  is  safe  to  say  that  the  loss  of 
this  tooth  in  early  life  shortens  a  man's  days  on  an  aver- 
age of  four  or  five  years. 

If  the  tooth  is  so  badly  decayed  that  only  the  roots 
are  good,  those  roots  ought  to  be  treated  and  filled  and 


56  Peactical  Oeal  Hygiene. 

kept  in  place  until  one  is  at  least  twenty  years  old.  Yon 
may  do  am^tliing  that  your  dentist  tells  you  to  do  except 
have  this  tooth  pulled.  If  he  insists  on  pulling  it,  then 
you  should  tell  your  mother  that  you  have  a  poor  den- 
tist, and  ask  her  to  let  3^ou  go  to  another.  It  is  very 
seldom  that  even  a  temporar}^  tooth  should  be  pulled  with 
forceps,  and  no  permanent  teeth,  except  the  wisdom 
tooth,  and  seldom  that  should  ever  lie  pulled.  If  you 
forget  everything  else  in  this  lecture,  don't  forget  what 
I  have  said  about  this  first  permanent  back  tooth.  Re- 
member that  it  is  yours  at  six  years  of  age  and  does 
not  replace  a  baby  tooth,  but  comes  behind  the  last  baby 
back  tooth. 

(*)  This  picture  shows  how  much  better  a  man  who 
has  not  lost  this  tooth  can  chew  than  one  who  has.  One 
has  at  least  one-fourth  more  grinding  efficiency  than  the 
other. 

(*)  When  this  fellow  was  a  boy,  he  didn't  chew  his 
food  or  brush  his  teeth,  so  they  soon  decayed  and  ached. 
He  had  two  of  his  upper  teeth  pulled.  His  upper  jaw 
stopped  growing,  but  his  lower  jaw  kept  on  growing,  so 
w^hen  he  got  to  be  a  man  his  teeth  didn't  fit  each  other 
and  his  jaws  were  not  the  same  size.  His  chin  pro- 
truded like  this  (Illustration),  and  he  looked  like  this. 

(*)  Do  you  want  to  look  like  thatf  Well,  you  had 
better  not  have  your  teeth  pulled  out. 

(*)  This  is  the  kind  of  dentist  who  pulls  teeth!  If 
your  dentist  looks  like  this  you  had  better  change  your 
dentist. 

(*)  This  picture  shows  how  the  adenoid  tissue  in  the 
naso-pliarynx  sometimes  becomes  enlarged  and  stops  up- 
the  air  passages,  so  that  you  cannot  breathe  freely 
through  your  nose.  This  makes  you  more  susceptible 
to  nose,  throat,  and  lung  trouble.  It  should  be  removed 
as  soon  as  discovered.  If  3^ou  are  accustomed  to  sleep 
with  your  mouth  open  and  breathe  through  your  mouth 
while  awake,  you  had  better  have  your  physician  ex- 
amine you  and  see  if  you  have  adenoids,  and  if  you  have,, 


Popular  Lectuees  ok  Dental  Subjects.  57 

they  should  be  removed.  They  frequently  spoil  the 
shape  of  the  mouth  and  make  the  teeth  crooked. 

(*)  This  is  the  way  the  teeth  frequently  look  when 
one  has  had  adenoids.  If  your  teeth  are  irregular  like 
these,  you  should  go  to  the  orthodontist  (the  dentist  who 
straightens  teeth)  and  have  them  straightened.  It  can 
be  easily  done  while  one  is  young,  but  if  you  wait  until 
you  are  old,  it  is  very  difficult. 

(*)  These  pictures  show  how  the  face  looked  before 
and  after  straightening  the  teeth.  The  teeth  are  much 
more  easily  and  thoroughly  cleansed,  and  are  therefore 
much  less  liable  to  decay  if  they  are  regular  and  straight 
and  fit  each  other  properly.  They  are  also  much  more 
efficient  grinders.  The  first  thing  for  you  to  do  is  to  see 
a  dentist  and  have  him  remove  all  deposits  which  you 
cannot  brush  off,  fill  all  cavities  and  put  your  mouth  in 
perfect  order  and  show  you  how  you  may  keep  it  so. 

In  making  the  dental  toilet,  the  first  thing  to  consider 
is  the  brush.  Any  kind  of  brush  is  better  than  no  brush, 
but  the  one  at  the  bottom  of  this  picture  is  too  large. 
Well,  it  is  not  too  large  to  brush  the  cow's  teeth  with, 
but  if  you  don't  weigh  more  than  two  hundred  pounds, 
it  is  too  large  for  you.  If  you  have  a  new  brush  as  long 
as  this  one,  you  can  improve  it  by  shaving  the  bristles 
off  for  about  the  length  of  the  brush.  You  will  then 
have  all  the  brush  that  you  will  be  able  to  use.  The 
brush  at  the  top  is  excellent.  It  has  a  long  tuft  of  bristles 
on  the  end  which  enable  you  to  reach  the  back  sides  of 
the  last  back  tooth.  The  narrow  nose,  broad  base  and 
short  body  makes  it  adaptible  to  the  various  situations 
and  the  curve  of  the  handle  is  an  advantage.  Brushes 
are  made  in  soft,  medium  and  stiff  bristles.  You  should 
use  a  soft  brush. 

The  next  consideration  is  a  tooth  powder.  ]\[ost  all 
tooth  powders  are  made  of  the  same  thing — Precipitated 
Chalk.  They  vary  mainly  in  the  perfumes  and  aromatic 
and  antiseptic  which  they  contain.  If  you  get  your 
mouth  clean  you  don't  need  a  perfume.    Perfume  in  a 


58  Peactical  Oeal  Hygiene. 

dentifrice  is  a  disadvantage,  because  it  deodorizes  the 
mouth  and  deceives  you.  A  pungent  aromatic  does  the 
same  thing  and  interferes  with  the  exquisite  sense  of 
touch  and  taste  in  the  tongue,  which  is  the  sanitary 
officer  of  the  mouth,  and  you  may  think  your  mouth  is 
clean  when  it  is  really  only  deodorized.  If  5^ou  can  get 
your  mouth  perfectly  clean,  you  do  not  need  an  antisep- 
tic, whereas,  if  you  fail  to  cleanse  it  thoroughly,  an 
antiseptic  is  of  slight  and  transient  value. 

Pass  the  brush  as  far  back  in  right  bu.ccal  pouch  as 
possible,  place  high  up  on  the  gums  above  last  upper 
back  tooth  and  bring  downward  with  a  rotary  sweep. 

You  will  see  that  as  the  bristles  slide  off  the  gums 
onto  the  teeth,  they  separate  and  sweep  out  the  triangu- 
lar spaces  about  the  necks  of  the  teeth.  Now  let  me  ask 
the  girls  a  question.  "If  you  were  going  to  sweep  the 
floor  of  a  street  car,  would  you  sweep  it  across  the  car 
or  down  towards  the  end  of  the  car?  When  you  are 
sweeping  the  teeth  to  get  them  clean,  will  you  sweep 
across  the  teeth  or  down  towards  the  end  of  the  teeth?" 
You  may  think  that  hard  to  do,  but  just  to  show  you  that 
it  is  not,  I  will  brush  mine  and  let  you  see.     (Illustrate). 

Place  bristles  of  brush  on  cheek  side  of  upper  right 
molar  gums  and  sweep  downward  five  strokes.  Move 
forward  to  bicuspid  region  and  repeat.  Go  back  to  cheek 
side  of  lower  molar  gums  and  sweep  upward  five  times. 
Move  forward  to  bicuspid  region  and  repeat. 

Place  brush  high  up  on  tongue  side  of  left  upper  molar 
gums  and  sweep  downward  with  a  rotary  stroke  five 
times.  Move  forward  to  region  of  bicuspids  and  repeat. 
Place  brush  on  tongue  side  of  lower  molar  gums  and 
move  upward  five  times.  Move  forward  to  bicuspids 
and  repeat. 

Take  brush  in  left  band,  place  brush  bigli  up  on 
cheek  side  of  upper  left  molar  gums  and  sweep  down- 
ward with  rotary  stroke  five  times.  Move  forward  to 
bicuspids  and  repeat.     Place  brush  low  down  on  cheek 


Popular  Lectures  o^r  Dek-tal  Subjects.  59 

side  of  lower  molar  gums  and  sweep  upward.  Repeat 
for  bicuspids. 

Place  brush  on  tongue  side  of  right  upper  molar 
gums  and  rotate  downward.  Same  for  bicuspids.  Same 
for  lower  molars  and  bicuspids.  Change  brush  to  right 
hand. 

Place  brush  high  up  on  lip  side  of  right  upper  canine 
gums  and  sweep  downward  working  around  to  left 
canine.  Pass  to  lip  side  of  lower  left  canine  gums  and 
sweep  upward  working  around  to  right  canine. 

Place  brush  high  up  in  roof  of  mouth  and  sweep  for- 
ward and  downward  over  right  canine.  Work  around 
to  left  canine. 

Place  brush  well  under  tongue  and  sweep  forward 
and  upward  over  left  canine.  Work  around  to  right 
canine. 

Place  brush  back  on  grinding  surface  of  right  upper 
molars  and  sweep  back  and  forth  to  bicuspids.  Same  on 
left  upper  molars  and  bicuspids. 

Place  brush  far  back  on  chewing  surface  of  left  lower 
molars  and  sweep  back  and  forth  to  bicuspids.  Same  on 
right  molars  and  bicuspids. 

Wash  brush  and  hang  up  to  dry.  Einse  mouth  vigor- 
ously with  tepid  water.  Use  tooth  pick  or  dental  floss 
between  all  teeth  and  behind  last  teeth.  Einse  mouth 
again. 

The  dental  toilet  should  be  performed  in  this  way 
before  retiring  and  before  breakfast.  Immediately  after 
eating  the  mouth  should  be  vigorously  rinsed  and  a  tooth 
pick  or  floss  used.  If  gums  are  soft  or  sore  they  should 
be  vigorously  massaged  with  the  pad  of  the  finger  once 
or  twice  daily. 

If  a  tooth  should  be  knocked  out  accidentally,  it 
should  be  washed  and  replaced  immediately  and  a  den- 
tist consulted  at  once. 

In  case  of  illness  the  mouth  should  be  kept  as  clean 
as  possible  both  mechanically  and  by  the  use  of  lime 


60  Practical  Oeal  Hygiene. 

water  and  other  antiseptics.    The  tongue  shonld  also  he 
frequently  cleansed  and  scraped. 

(*)  What  is  the  matter  with  this  little  fellow?  Did 
yon  ever  have  toothache?  Did  you  cry?  If  you  will  fol- 
low the  instructions  given  in  this  lecture  you  need  never 
have  toothache  again. 

It  is  not  what  we  learn  that  makes  us  wise  and  happy, 
it  is  what  we  remember  and  practice. 

LECTUEE    FOR    SCHOOL    CHILDREN",    BY    GEORGE    EDWIN    HUNT, 
M.  D.,  D.  D.  S.,  DEAN  OF  THE  INDIANA  DENTAL  COLLEGE. 

"Now,  young  ladies  and  gentlemen,  I  nm  here  today 
to  give  you  a  talk  about  the  mouth  and  teeth,  and  since 
it  is  easier  to  ask  questions  than  to  answer  them,  I  am 
going  to  begin  by  asking  you  a  question  or  two.  The 
reason  wh}^  your  teachers  ask  you  so  many  questions*,  is 
because  it  is  easier  to  ask  them  than  to  answer  them. 
The  first  question  I  am  going  to  ask  is,  'How  many  of 
you  washed  your  faces  before  you  came  to  school  this 
morning?  Hands  up.'  Well,  that's  good.  I  guess  every- 
body washed  their  faces  before  they  came  to  school  this 
morning.  There's  one  boy  over  there  in  the  corner  that 
only  put  his  hand  up  part  way,  but  I  guess  he  must  have 
washed  for  a  high-necked  collar.  Now,  I'm  going  to  ask 
another  question,  'How  many  of  you  cleaned  your 
mouths  before  you  came  to  school  this  morning?'  Ah! 
that's  not  quite  so  good.  Quite  a  number  of  you  did,  but 
there's  quite  a  number  of  you  that  did  not.  Now,  in  my 
opinion,  if  you  are  going  to  make  a  choice  between  these 
two  things,  I  think  you  should  clean  your  mouths  and 
not  wash  your  faces,  but  if  I  were  you  I  would  do  both, 
because  if  you  don't  wash  your  faces  you  won 't  look  very 
pretty,  and  if  you  don't  clean  your  mouths,  a  lot  of  other 
tilings  are  going  to  happen  to  you  that  I'll  tell  you  about. 

"Now  for  another  question,  'How  many  of  you  ever 
had  toothache?'  My  goodness!  Nearly  everyone  of  you 
has  had  the  toothadie.     And  those  of  vou  that  haven't 


PopuLAE  Lectures  on  Dental  Subjects.  61 

had  tootli-aclie  certainly  liave  seen  people  having  tooth- 
ache and  know  what  it  is  like.  Suppose  I  tell  you  what 
makes  your  teeth  ache.  In  order  to  do  it,  I  am  going 
to  ask  you  another  question.  I  am  a  great  fellow  for 
asking  questions.  'Suppose  the  evening  meal  was  over 
and  everybody  had  left  the  dining  room  but  mother,  and 
mother  is  clearing  up  the  table.  She  finds  some  nice 
boiled  potatoes,  and  here  is  a  nice  piece  of  meat  too 
large  to  be  thrown  away,  and  here  are  some  other  veg- 
etables that  she  can  keep  until  to-morrow.  Maybe  she 
will  chop  up  that  meat  and  put  potatoes  with  it  and  have 
hash  for  breakfast.  When  mother  makes  hash  it  is  a 
pretty  good  thing  to  eat.  Now,  where  does  mother  put 
that  food  to  keep  it  until  to-morrow,  so  that  it  will  be 
nice  and  fresh!'  (A  pupil — 'In  the  ice  box.')  Yes,  she 
puts  it  in  the  ice  box.  But  why  does  she  put  it  in  the 
ice  box!  Why  not  just  put  it  out  on  the  back  steps  where 
the  sun  will  shine  on  it  and  the  rain  will  fall  on  it?  Now, 
we  wont  say  anything  about  the  dog  or  the  cat  getting 
it  or  the  birds  carrying  it  away,  but  just  tell  me  what 
happens  to  food  if  she  were  to  do  that?  (A  pupil — 'It 
would  rot  or  decaj-.')  That's  it.  It  would  rot  or  decay. 
Well,  that's  just  exactly  what  happens  to  food  in  your 
mouth.  That  isn't  very  pleasant  to  think  about,  is  it? 
Every  time  jou  eat,  you  leave  some  particles  of  the  food, 
no  matter  what  kind  of  food  it  is,  about  the  necks  of  the 
teeth  and  in  between  the  teeth,  and  if  it  isn't  removed 
that  food  rots  or  decays  just  as  the  food  from  the  dinner 
table  would  do  if  mother  put  it  out  in  the  sun  and  rain. 
Now,  when  that  food  rots  in  the  mouth  there  are  certain 
acids  formed,  so  you  are  carrying  around  a  sort  of  acid 
factory  in  your  mouth  and  nobody  wants  to  feel  that  they 
are  an  acid  factory.  This  acid  dissolves  the  tooth  just 
as  water  will  dissolve  sugar  when  you  pour  the  sugar  in 
the  water  and  stir  it  up,  although  it  does  not  dissolve  it 
nearly  so  fast.  But  it  dissolves  it  just  a  little  at  a  time 
and  the  first  thing  you  know  that  tooth  has  a  cavity  in 
it.     A  little  later  on  that  cavity  gets  deeper  and  pretty 


62  Peactical  Oral  Hygiene. 

soon  the  tooth  begins  to  aclie.  And  that's  the  way  yon 
have  decayed  teeth  and  have  toothache.  Don't  yon  think 
it  would  be  better  not  to  leave  those  particles  of  food 
aronnd  the  teeth  so  that  the}'  will  form  acid  and  give  yon 
toothache? 

''There  are  three  reasons  why  I  think  yon  ought  to 
take  care  of  jour  teeth.  The  first  reason  is  that  you  will 
not  have  pain.  The  second  reason  is  that  your  health 
may  be  better.  The  third  reason  is  that  yon  may  be  more 
beautiful.  Now,  when  I  talk  about  being  more  beauti- 
ful, these  boys  laugh  in  their  sleeves  because  they  think 
they  don't  care  whether  they  are  beautiful  or  not,  but 
we  girls  know  that  in  a  few  years  from  now  we  will 
wish  we  were  good  looking,  don't  we? 

"Now,  in  regard  to  the  first  of  these  three  reasons. 
You  have  told  me  that  nearly  all  of  you  have  had  tooth- 
ache and  that  those  who  have  not  had  toothache  have 
seen  people  who  were  having  toothache,  so  that  I  don't 
think  it  is  necessary  to  spend  any  time  in  telling  you  that 
toothache  is  not  a  good  thing  to  have.  Nobody  would 
go  around  hunting  for  a  toothache.  So  we  will  just  take 
it  for  granted  that  you  know  that  you  don't  want  a 
toothache  and  think  that  your  teeth  should  be  cared  for 
on  that  account. 

"Now  for  the  question  of  health.  You  have  all  heard 
of  a  certain  part  of  the  body  which  has  an  awfully  long 
name,  and  which  it  is  difficult  for  me  to  remember,  but  I 
can  sometimes  recall  it— the  alimentary  canal.  It  is  in 
this  alimentary  canal  where  all  digestion  of  food  takes 
place,  and  if  it  wasnt  for  the  the  alimentary  canal,  we 
would  all  starve  to  death.  I  don't  know  whether  you 
know  it  or  not,  but  the  alimentary  canal  in  grown-u]is  is 
over  thirty  feet  long.  That  would  make  a  person  awfully 
tall  if  the  alimentary  canal  was  straight,  but  it  isn't 
straight.  Now  here's  the  point  I  want  to  make.  In  that 
whole  thirty  odd  feet  of  the  alimentary  canal  there  are 
only  three  inches — these  three  inches  from  the  teeth  to 
the  back  of  the  mouth — over  which  you  have  control  of 


PopuLAE  Lectures  on  Dental,  Subjects.  63 

your  food.  Now,  since  digestion  starts  here  in  the  month 
and  digestion  cannot  start  properly  unless  this  food  is 
well  chewed,  and  since  yon  have  no  control  over  the  food 
after  yon  swallow  it,  don't  yon  think  it's  a  good  plan  to 
take  care  of  it  while  yon  have  a  chance  to  do  so? 

''Now  I'm  going  to  tell  you  how  to  eat.  I  expect  you 
think  you  know  how  to  eat  but  I  don't  believe  you  do, 
and  I'm  going  to  ask  yon  to  do  something  for  me.  A¥hen 
you  go  to  the  supper  table  this  evening,  I  want  you  to 
take  a  bite  of  bread  and  butter  out  of  the  middle  of  the 
slice.  Don't  get  any  of  the  crust,  but  just  get  the  soft 
inside  of  the  slice.  Then  see  how  long  you  can  chew  that. 
Kow  you  probably  think  you  can  chew  it  just  as  long  as 
you  please  but  you  can't.  After  a  while,  and  it  won't 
be  very  long  either,  you  will  find  that  there  is  nothing 
in  your  mouth.  You  have  swallowed  that  bread  and 
butter  and  didn't  know  when  you  did  it.  That's  the  way 
you  ought  to  chew  most  foods.  You  can  chew  potatoes 
that  way  and  most  cooked  vegetables,  but  not  all  of  them. 
Then  there  are  some  foods  you  can't  chew  that  way  at 
all,  so  they  will  swallow  themselves.  Unless  you  get 
better  beefsteak  here  than  we  do  where  I  live,  you  can't 
chew  beefsteak  that  way,  and  unless  you  get  better  celery 
here  than  I  do,  3^ou  can't  chew  celery  that  way,  because 
it  is  stringy  and  you  can't  alwaj^s  chew  string  beans  that 
way  unless  they  are  very  well  unstrung.  However,  those 
foods  that  you  can't  chew  until  they  swallow  themselves, 
should  be  chewed  until  there  is  no  longer  any  taste  to 
them.  Then  you  can  swallow  them  all  right.  Now  if  you 
would  chew  5^our  foods  that  way,  it  would  be  a  great 
thing  for  your  teeth  and  gums,  and  I  am  sure  you  would 
enjoy  it  more  if  you  would  once  get  in  the  habit  of  eat- 
ing in  that  manner  and  your  health  would  be  very  much 
better. 

''Now,  girls,  I  am  going  to  talk  to  the  boys  a  few 
minutes  and  you  can  listen  if  you  want  to.  How  many 
of  you  boys  ever  heard  of  a  game  called  base  ball?  Well, 
I  guess  most  of  von  know  all  about  base  ball.     "Well,  if 


64  Peacticajl  Oeal  Hygiene. 

you  boys  want  to  be  good  base  ball  players,  or  good  foot 
ball  players,  or  good  tennis  players,  or  good  in  any  other 
line  of  athletics,  you  have  to  have  good  teeth,  and  you 
have  to  use  them  properly.  Now  maybe  you  think  that 
is  a  funny  thing  for  me  to  say.  But  don't  you  see,  that 
since  digestion  starts  in  the  mouth,  that  if  you  don't  have 
good  teeth  to  chew  your  food  with  and  don't  use  your 
teeth  properly  you  won't  have  good  digestion.  Nobody 
with  poor  digestion  can  ever  be  a  good  athlete.  Did  any 
of  you  boys  ever  hear  of  Connie  Mack,  or  John  McGraw? 
Why  of  course  you  have.  Connie  Mack  is  manager  of 
the  Philadelphia  Athletics,  the  champion  base  ball  team 
of  the  world,  and  John  McGrraw  is  manager  of  the 
New  York  Giants,  which  is  the  second  best  team  in  the 
world.  Well,  when  the  Athletics  and  Giants  report  early 
in  the  spring  for  spring  practice  and  to  go  to  the  training 
ground,  Connie  Mack  and  John  McGraw  make  them  go 
to  the  dentist  and  have  their  mouths  put  in  order  before 
they  can  ever  begin  training.  Now,  Connie  Mack  and 
Johnnie  McGraw  don't  care  whether  those  ball  players 
of  theirs  are  pretty  or  not,  nor  they  don't  care  particu- 
larly whether  those  ball  players  have  pain  or  not,  but 
they  do  know  that  if  the  ball  players  mouths  are  not  in 
good  condition  that  they  can't  play  ball  as  well  as  they 
could  if  their  mouths  were  in  good  condition.  Suppose 
there  was  a  World  Series  on  and  the  Athletics  had  won 
three  games  and  the  Giants  had  won  three  games  and 
the  next  game  was  to  decide  the  world's  championship. 
And  suppose  the  next  morning  Baker,  of  the  Athletics, 
their  best  batter,  were  to  show  up  at  the  ball  ground 
with  his  face  swollen  out  with  an  abscessed  tooth.  He 
couldn't  play  base  ball  that  day.  Even  if  he  tried  he 
couldn't  play  well.  And  his  absence  from  the  team  might 
cause  the  Athletics  to  lose  the  world's  championship.  So 
you  see  that  to  athletes,  bad  teeth  are  a  great  handicap. 
Connie  Mack  knows  that  and  that's  why  he  insists  that 
Baker's  teeth  shall  be  in  good  condition  and  that  he  shall 
keep  them  in  good  condition   all  through  the  playing 


PopuLAE  Lectures  on  Dental  Subjects.  f)5 

season.  He  knows  that  Baker  wouldn't  play  as  good 
base  ball  if  he  had  a  mouth  full  of  bad  teeth. 

''And  now  you  girls.  You  like  your  roller  skates,  and 
you  like  to  play  tennis,  and  you  like  to  dance,  and  you 
like  to  do  a  lot  of  other  things  that  depend  a  great  deal 
uj)on  the  condition  of  your  health.  Then  you  don't  want 
to  have  indigestion  and  headaches  and  all  those  kind  of 
troubles  when  you  are  gromng  up  because  they  inter- 
fere with  your  school  work  just  as  they  interfere  with 
the  boys  school  work  also.  And  unless  your  teeth  are  in 
good  shape  and  you  use  your  mouth  properly,  you  will 
not  be  in  good  health.  Nobody  in  school  can  do  their 
best  work  and  keep  up  with  their  studies  if  they  are 
suffering  with  tooth-ache,  or  if  they  are  suffering  from 
indigestion,  because  of  the  condition  of  their  mouths. 
You  don't  want  to  fall  behind  in  your  classes  and  have 
to  take  a  part  of  the  work  over  again,  and  yet  you  can't 
keep  up  with  your  classes  unless  your  health  is  good  and 
your  health  can't  be  good  unless  your  mouth  is  in  good 
condition.  So  you  see,  your  health  depends  a  good  deal 
upon  the  condition  of  your  mouth. 

''Now  to  take  up  the  third  reason  why  you  should 
care  for  your  mouths.  You  boys  may  not  think  now 
that  it  makes  any  difference  whether  your  mouths  look 
good  or  not,  but  it  does.  Pretty  soon  now,  you  boys  will 
have  to  get  out  in  the  world  and  earn  your  own  living. 
Your  fathers  and  mothers  have  been  pretty  good  to  you 
so  far,  but  they  can't  take  care  of  you  always,  and  after 
a  while  you  have  to  earn  money  for  yourselves.  Then 
again,  later  on,  perhaps,  you  will  have  to  be  earning 
money  to  take  care  of  one  of  these  girls,  also.  Now, 
suppose  a  wholesale  merchant  in  this  town  wanted  a  boy 
to  come  into  his  establishment  and  start  way  down  at 
the  foot  of  the  ladder,  with  a  prospect  of  working  up.  It 
may  be  the  boy  could  get  to  be  a  general  manager  of  the 
institution  after  a  number  of  years,  or  head  bookkeeper 
or  some  good  paying  job.  Suppose  two  boys  apply  for 
this  job.     One  of  them  has  a  mouth  full  of  dirty  teeth, 


66  Peactical  Oeal  Hygieiste. 

witli  green  scum  on  them,  cavities  sliowing  in  the  front 
teeth,  month  foul  as  can  be,  breath  bad  on  account  of  his 
decayed  teeth,  perhaps  one  or  two  teeth  gone.  The  other 
boy  has  a  mouth  that  shows  that  he  has  taken  care  of  his 
teeth,  that  he  cleans  his  mouth,  and  takes  some  pride  in 
it.  Which  one  of  those  two  bo^^s  will  the  merchant  hire, 
other  things  being  equal?  He'll  hire  the  bo}'  with  the 
clean  mouth.  He  will  say  to  himself,  'This  boy  with  the 
clean  mouth  takes  some  pride  in  his  appearance  and  is 
more  likely  to  take  pride  in  his  work.  This  boy  with  the 
dirty  mouth  is  very  likely  to  be  slovenly  about  his  work.' 
And  then  again,  the  merchant  would  argiie  to  himself, 
the  boy  with  the  bad  mouth  is  more  likely  to  lose  time  and 
neglect  his  work  on  account  of  toothache  than  the  boy 
with  the  good  mouth.  So  you  see  that  it  does  pay  you 
to  have  good  looking  mouths,  even  in  business,  and  it 
pays  you  girls,  too.  Of  course,  you  are  more  likeh'  to 
have  pride  in  your  looks  than  the  boys  are,  but  from  a 
purely  business  standpoint  3'ou  ought  to  take  care  of 
your  teeth.  If  jou  grow  up  and  have  to  earn  3"our  own 
livings  or  want  to  make  a  little  extra  money  working 
in  an  office  or  store,  you  will  find  that  you  can  get  work 
a  good  deal  quicker  if  you  have  nice  looking  mouths  and 
nice  looking  teeth,  than  you  can  without  them.  Mer- 
chants don't  like  to  hire  a  girl  in  their  store  to  sell  goods 
to  customers  if  their  mouth  is  in  such  shape  that  their 
breath  is  bad  and  their  appearance  is  bad.  Everybody 
ought  to  be  as  handsome  as  they  can  in  this  world,  be- 
cause other  people  have  to  look  at  them  and  they  ought 
to  make  it  as  easy  for  the  other  people  to  look  at  them 
as  they  can.  So  those  are  the  three  reasons  why  I  think 
you  ought  to  take  care  of  your  mouth  and  teeth,  and  now 
having  told  you  all  of  this  about  what  will  happen  to 
you  if  you  don't  take  care  of  them,  I  think  I  ought  to  tell 
you  how  to  take  care  of  them. 

"But,  first  let  me  tell  you  how  often  you  ought  to 
clean  your  mouth.  Of  course,  if  you  could  do  it,  it  would 
be  better  for  you  to  clean  your  mouths  every  time  you  eat 


Popular  Lectures  on  Dental  Subjects.  67 

anything,  but  that  isn't  always  possible.  I  think,  if  I 
were  you,  I  would  rinse  my  mouth  out  with  water  the 
first  thing  when  I  get  up  in  the  morning.  Then  after 
breakfast,  I  would  use  my  toothbrush  and  the  floss  silk 
in  the  way  that  I  will  describe  to  you,  and  then  if  you 
don't  clean  them  again  until  just  before  you  go  to  bed, 
you  will  have  done  pretty  well,  anyhow.  Always  give 
3"our  mouth  a  good  cleaning  just  before  going  to  bed.. 
Dion't  forget  that,  because  it  is  very  important. 

"  (Now  the  lecturer  should  give  a  talk  on  the  toilet 
of  the  mouth.  If  stereoptican  views  could  be  shown, 
they  can  be  begun  at  any  point  in  the  talk  that  the  lec- 
turer desires.  Personally,  I  begin  showing  my  stereopti- 
can views  as  soon  as  I  have  wound  up  my  argument  for 
good  teeth.  That  is,  just  before  this  talk  starts  in  on 
telling  them  how  to  take  care  of  their  mouths.) " 


CHAPTEE     V. 

DENTAL  EXAMINATION  AND  CLINIC  FOR 
PUBLIC  SCHOOLS. 

HISTORY. OBJECT    OF    SCHOOL    USTSPECTION. HOW    TO    START 

SCHOOL  INSPECTION. ARGUMENT  FOR  FREE  DENTAL 

CLINICS  AND   SCHOOL  INSPECTION. 

Dental  examination  in  public  schools  consists  of  in- 
specting and  tabulating-  the  oral  conditions  of  the  stu- 
dents, by  some  dentist  under  authority  of  the  local  dental 
society  or  public  school  authority. 

HISTORY. 

It  is  of  interest  to  note  that  in  1879  Eussia  started 
this  inspection.  Chicago,  some  thirty  years  ago,  was  the 
first  city  in  the  United  States  to  have  this  work.  Ann 
Arbor,  Mich.,  was  one  of  the  first  cities  to  make  this  in- 
spection under  the  supervision  of  the  school  board.  Cam- 
bridge, in  1907,  had  the  first  school  dental  clinic  operated 
in  this  country.  Nearly  all  the  foreign  countries  have 
made  great  strides  in  this  direction,  and  x^merica  has,  at 
last,  awakened  to  the  need  of  this  work.  Nearly  every 
state  in  the  Union  is  now  doing  some  work  along  this 
line. 

OBJECT   OF   SCHOOL  INSPECTION. 

The  object  to  be  gained  by  the  inspection  of  the  teeth 
of  scliool  children  is : 

First,  to  show  the  people  and  the  parents  the  actual 
existing  conditions.  To  tell,  for  instance,  that  in  New 
York  the  examinations  show  such  and  such  defects,  is  not 
as  interesting  as  to  show  them  the  conditions  in  their  own 
children's  mouths. 

Second,  to  increase  the  working  capacity  of  the  child. 


Dental  Ixspectiox  ix  Schools.  fiP 

Third,  to  accumulate  data  which  will  in  the  future 
force  the  people  to  wake  up  on  this  subject. 

Fourth,  to  show,  by  comparison  with  schools  that 
have  established  this  system,  what  can  be  done. 

All  statistics  of  school  examinations  show  that  dental 
lesions  are  in  the  majority  of  all  defects,  ranging  from 
80  to  98  per  cent. 

One  of  the  objections  that  will  arise  in  the  minds  of 
the  school  board,  whether  expressed  or  not,  will  be  that 
thej  invariably  think  that  the  dentists  have  some  ulterior 
motive,  or  that  they  are  ambitious  to  advance  themselves. 
This,  of  course,  can  be  met  with  the  fact  that  the  dentist, 
in  many  instances,  is  domg  the  work  free  of  charge,  and, 
in  addition,  is  furnishing  material,  charts,  and  stationery 
at  his  own  expense.  Medical  examiners  are  generally 
paid  a  salary  or  else  a  fee  for  some  special  examinations. 

HOW    TO    STAKT    DEXTAL    SCHOOL    IXSPECTIOX. 

As  nearly  all  schools  have  some  sort  of  medical  ex- 
amination or  supervision,  the  beginning  of  deiital  atten- 
tion must,  of  necessity,  be  done  through  the  medical 
examiner.  It  is  a  good  start  for  the  dentist  of  local 
society  to  secure  the  medical  examiner's  sympathy  and 
co-operation.  Have  him  visit  some  dental  office  and  show 
him  b}^  pictures  and  by  examination  of  a  patient  what  to 
look  for  and  how  to  find  defects  in  children's  mouths. 
Mail  him  reprints  from  the  dental  journals  on  the 
subject. 

In  attempting  to  start  dental  inspection  or  clinics  in 
a  new  place,  the  dentist  often  finds  a  lack  of  interest  or 
even  opposition  on  the  part  of  the  commissioners  of  edu- 
cation and  the  teachers.  This  is  humiliating.  On  the 
other  hand,  we  have  found  that  physicians  do  not  have 
to  beg  the  schools  to  accept  their  services,  but  are  wel- 
comed, and  the  necessary  funds  are  forthcoming  for  their 
enterprise.  It  is  even  necessary  sometimes  for  dentists 
to  beg  to  put  in  dental  inspection  in  one  school  just  to 


70  Peactical  Oeal  Hygiene. 

show  these  men  from  "Missouri"  wliat  can  be  clone. 
This  is  the  one  place  where  it  is  better  to  work  first  with 
the  medical  examiner.  Go  to  him,  teach  him  how  to  ex- 
amine for  dental  defects,  and  then  get  him  to  state  in  his 
reports  the  dental  defects  which  he  has  foimd.  This  will 
do  the  authorities  more  good  than  forty  dentists  going 
before  them.  After  the  medical  examiner  has  done  this, 
you  have  the  entering  wedge. 

When  the  medical  examiner  has  made  his  report,  the 
next  man  to  see  is  the  superintendent  of  the  schools,  for 
he  is  the  man  who,  unless  seen  first,  is  going  to  make 
objection.  Put  the  facts  up  to  him  as  given  in  our  chap- 
ter on  Oral  Hygiene.  Explain  to  him  that  it  is  not  plac- 
ing a  burden  on  his  pupils,  but  taking  a  burden  off  of 
them.  If  you  can  win  his  co-operation,  one-half  of  the 
battle  is  won.  Take  him  along  with  you  to  see  the  presi- 
dent of  the  board  of  ©education,  and  at  a  special  meeting 
have  a  committee  along  with  reliable  facts  on  oral  sepsis, 
and  show  literature  and  statistics  from  other  schools 
which  have  inaugurated  this  system.  Show  them  how 
pupils  with  dental  irritation  are  unfit  for  study.  Offer 
to  make  a  voluntar}^  inspection  of  one  school  at  the  open- 
ing of  the  term  and  at  the  close  of  the  term.  Have  pre- 
pared blanks  somewhat  on  the  order  of  those  shown  in 
this  book,  and  then  the  next  year  when  it  goes  before  the 
board  of  education,  meet  them  on  a  plain  business  basis. 
After  you  have  secured  consent  for  the  first  examination, 
see  that  the  parents  are  acquainted  with  the  conditions 
of  the  children's  mouths,  and  that  the  child  is  interested 
through  popular  lectures  in  prophylaxis,  tooth  brushes, 
and  dentifrice.  It  is  also  well  to  have  some  slides  with 
pointed  paragraphs  on  them  or  printed  cards.  Stop  in 
the  lecture  and  write  these  points  on  the  black-board 
every  few  minutes.  A  break  in  a  lecture  like  this  has  a 
good  impression.  Statements  like  the  following  should 
be  used: 

"A  Clean  Mouth  Prevents  Pain  and  Illness." 
"Food  Left  Between  Teeth  Causes  Decay." 


Dental  Inspection  in  Schools.  71 

"Dirty  Mouths  Breed  Disease  Germs." 

''A  Clean  Tooth  Never  Decays." 

' '  Clean  Your  Teeth  After  Eating. " 

Sometimes  it  is  necessary  to  use  some  other  attrac- 
tive schemes  to  produce  results.  In  "Wilkshurg,  Pa.,  the 
dental  society  devised  a  plan  by  which  the  children  were 
induced  to  use  the  tooth  brush  and  dentifrice  furnished 
by  the  society.  With  each  package,  a  check  was  given 
to  the  children.  Five  of  these  checks  would  secure  a 
package  free.  The  checks  were  given  out  by  the  teachers 
for  keeping  the  teeth  clean  and  owning  a  tooth  brush. 
The  reports  from  the  use  of  such  schemes  seem  to  indi- 
cate that  they  are  proving  their  worth ;  the  statistics  col- 
lected by  the  dental  examiners  have  been  highly  satisfac- 
tory, and  the  parents  of  the  children  have  shown  a  keen 
interest  in  the  work. 

As  evidence  of  further  progression  in  this  work.  Dr. 
A.  C.  Fones  writes  me  as  follows : 

"If  our  plans  go  through  here  in  Bridgeport,  we  will 
start  a  preventive  and  educational  dental  clinic  in  our 
public  schools  in  September,  and  intend  to  educate  dental 
nurses  to  put  them  in  one  school  as  a  demonstration,  and 
see  that  the  children  have  a  surface  treatment  once  a 
month." 

Before  beginning  the  school  inspection,  it  is  well  to 
have  printed  the  proper  charts,  the  best  of  which  are 
shown  in  this  book  in  the  following  pages.  Several  ad- 
justable head  rests  attached  to  common  chairs,  can  be 
used  for  the  examination.  The  examination  should  be 
made  in  a  room  separate  from  the  class  room,  and  three 
or  four  students  called  out  together.  It  is  well  to  have  a 
trained  nurse  to  attend  to  the  sterilization  of  the  instru- 
ments. The  assistance  of  several  young  dentists,  who 
will  generally  be  glad  to  give  their  services,  should  be 
arranged.  The  cards  should  be  given  to  the  students  be- 
fore they  reach  the  examining  room,  with  name  and  grade 
filled  in.  Since  we  do  not  have  to  include  in  our  report 
all  the  minor  defects  which  are  found,  the  examination 


72  Practical  Oral  Hygiene. 

of  about  fifty  cliilclren  an  hour  can  be  counted  on  as  an 
average.  Specific  information  should  not  be  given  on  the 
card  which  is  sent  to  the  child's  parents,  as  the  repu- 
tation of  the  family  dentist  must  be  protected  for  the 
good  of  all.  The  only  object  of  the  examination  being 
to  let  the  parents  know  that  they  should  have  either  their 
family  dentist,  or  the  school  clinician  to  make  further 
or  more  extensive  examination  of  the  teeth. 

After  the  examination  is  complete,  the  popular  lec- 
tures should  be  begun  and  the  children  and  their  parents 
invited.  At  these  lectures  the  statistics  of  the  examina- 
tion should  be  shown,  and  means  of  improvement 
stressed.  All  the  while  the  first  point  in  this  move- 
ment is  to  remove  the  child's  apatlw  towards  the  dentist, 
and  to  urge  the  necessity  for  oral  hygiene  measures.  Get 
the  child  so  interested  that  he  will  insist  on  the  repair 
of  the  defects.  The  dental  colleges  should  be  specially 
instructed  to  help  in  this  work.  In  those  places  where 
there  is  no  dental  college,  and  where  there  is  not  time 
to  establish  a  dental  clinic,  the  practitioners  must  give 
certain  hours  to  this  free  work  for  those  who  cannot  pay 
for  it,  for,  the  failure  to  repair  these  defects  found  in 
the  teeth  of  the  children,  would  result  in  upsetting  all  the 
plans  for  prophylaxis  work  in  the  future. 

reasons  for  free  dental  clinic  and  school  inspection. 

It  saves  money  for  the  county  and  state,  for  much  of 
the  expense  of  teaching  goes  to  laggards,  and  a  large  per 
cent,  of  the  laggards  are  made  so  by  some  physical  de- 
fect. The  largest  number  of  physical  defects  lies  in  the 
teeth.  This  corrected,  the  laggards  become  normal  in 
their  class  rooms.  By  putting  the  laggards  through 
school  each  year,  the  school  is  saved  the  expense  of  hav- 
ing to  teach  the  pupils  two  years  the  same  subject.  It 
has  l)een  said  that  schools  expend  about  twenty  per  cent, 
of  their  income  on  this  kind  of  double  teaching.  Another 
of  the  greatest  drawbacks  to  successful  teaching  is  from 
absentees.  A  large  per  cent,  of  absences  from  school, 
is  from  toothache.    This  remedied,  the  pupil  is  more  apt 


Dental  Inspection  in  Schools.  73 

to  be  regular  in  attendance,  and,  consequently,  can  better 
concentrate  liis  mind  on  Ms  studies. 


Fig.  G.    a  Rochester  School  Boy  Patient  of  the  Free  Dextal 
Dispensaries. 

"Handieapped  in  his  school  work,  health,  appearance  and  ability  to 
secure  or  hold  a  position.  It  is  necessary  for  him  to  leave  school  to 
help  support  the  family.  Who  Avants  to  employ  a  boy  with  a  mouth 
such  as  this?  We  remove  the  handicaps  and  enable  this  lad  to  start 
even  with  his  associates.  This  charitj'  does  not  iDauperize  the  recip- 
ient." 

Dental  inspection  in  our  public  schools  not  only  edu- 
cates tbe  children  along  these  lines,  but  it  also  enables 
us  to  teach  the  parents  what  they  can  and  should  do  for 
the  younger  generation  in  the  way  of  preventing  disease. 
The  laity,  being  so  ignorant  on  the  subject  of  oral  sepsis, 
shiould  be  given  every  opportunity,  and  should  have  im- 
pressed on  their  minds  the  close  relation  between  these 


74  Peactical  Oeal,  Hygiene. 

conditions  and  the  general  health.  I  have  requested  the 
privilege  of  publishing  a  personal  letter  from  Dr.  Zar- 
baugii.     It  contains  the  best  argument  for  our  work  in 

the  public  schools : 

Toledo^  Ohio^  Thursday,  Oct.  30tb,  1913. 

Dr.  Robin  Adair, 
Atlanta,  Ga. 

My  Dear  Doctor  Adair:  Enclosed  please  find  my  eti'ort  on  behalf 
of  the  school  children  of  America.  I  could  not  speak  the  volume  that 
is  in  my  heart  on  this  subject,  because  ours  is  an  empty  home,  made 
so  by  the  neglect  of  someone  in  alloAving  a  child  to  return  to  school 
who  had  been  ill  -with  scarlet  fever,  without  thoroughly  cleaning!  the 
mouth. 

I  have  looked  into  the  diseases  of  childhood  pretty  thoroughly,  and 
I  find  that  absolutely  nothing  has  been  offered  the  medical  men  in  the 
way  of  treatment  but  serumtherapy,  and  no  progress  has  been  made  in 
preventing  them,  except  what  we  of  the  Dental  profession  are  able  to 
do  in  the  oral  hygiene  movement.  I  believe  that  it  is  our  greatest  field 
in  which  to  work  for  humanity. 

Ours  was  a  bright,  fair,  blue-eyed  boy  9  years  old,  sick  one  week, 
bid  us  goodby  after  telling  us  that  he  was  going  to  heaven,  kissed  us 
with  a  smile  on  his  lijos  and  ijassed  on. 

The  same  tragedy  is  being  enacted  in  many  homes  at  this  veiy 
moment,  and  the  sad  thing  about  it,  is,  that  it  could  have  been  and  can 
he  prevented. 

Yours  very  truly, 

Lyman  L.  Zarbaugii. 

importaisrce  or  dental  inspection  of  school 
children's  teeth. 

by  lyman  l.  zarbauc4h,  d.  d.  s.,  toledo,  ohio. 

'^If  the  annual  losses  to  the  parents  and  guardians  of 
the  school  children  of  America  and  to  the  children  them- 
selves were  focused  into  a  single  line  of  figures,  the  re- 
sult would  look  like  an  astronomical  calculation. 

''According  to  figures  given  where  inspection  of 
school  children's  teeth  have  been  made  in  schools,  ninety 
to  ninety-five  jjer  cent,  have  defective  teeth. 


J)extal  Inspection  in  Schools.  75 

"Tliousauds  upon  thousands  of  dollars  are  wasted 
each  year.  Untold  suffering,  great  loss  of  time  in  scliool 
from  toothache,  mental  disturbances,  etc.,  result  because 
of  the  ignorance  of  parents  regarding  their  children's 
teeth.  This  suffering  and  loss  of  time  and  money  can  be 
stopped  very  quickly  and  effectively  by  the  inspection  of 
school  children's  teeth  by  a  dentist  twice  a  year. 

"To  illustrate  the  loss  in  dollars,  one  of  the  thousands 
of  cases  is  cited.  A  child  at  the-  age  of  six  years  erupts 
the  first  permanent  molar.  Because  of  faulty  develop- 
ment, a  small  opening  between  the  folds  of  enamel  at  the 
developmental  lines  allows  decay  to  progress.  No 
amount  of  brushing  or  anything  else  will  save  that  tooth 
except  a  properly  inserted  filling.  Now  it  is  perfectly 
plain  that  if  that  child's  teeth  are  inspected  at  the  be- 
ginning and  close  of  the  school  year,  the  cavity  or  defect 
will  be  found,  and  the  fault  remedied  if  the  parents  heed 
the  warning.  If,  on  the  other  hand,  no  inspection  be 
held,  the  tooth  continues  to  decay  for  a  year  or  more, 
and  the  child,  after  the  tooth  is  nearly  ruined,  complains 
of  toothache.  The  dentist  is  visited.  He  finds  the  pulp 
exposed  or  putrescent,  necessitating  tedious  treatment 
and  expensive  restoration,  costing  an^ns^here  from  five  to 
eight  dollars ;  whereas,  if  the  matter  had  been  brought 
to  the  attention  of  the  parent  at  the  start,  the  cost  would 
not  have  exceeded  one  dollar  at  most,  and  very  likely 
less,  to  say  nothing  of  the  loss  of  time,  and  pain  and 
suff'ering  of  the  child. 

"Dental  inspection  can  be  likened  to  the  watchmen  in 
large  buildings  and  factories  who  make  their  rounds 
every  hour,  pulling  the  boxes.  They  are  looking  for  fire. 
If  they  find  it,  the  fire  department  is  called  and  the  dam- 
age is  slight.  Just  so  with  dental  inspection  in  schools. 
The  damage  to  teeth  would  be  very  slight  indeed.  No 
tooth  would  decay  in  six  months'  time  sufficient  to  cause 
any  real  trouble  or  suffering. 

"The    coming    generation    would    never    experience 


76  Peactical  Oral  Hygiene, 

tootliache  and  loss  of  teeth,  if  dental  inspection  in  the 
schools  were  universal  and  the  warnings  heeded.  People 
wearing  artificial  teeth  would  be  a  curiosity  in  a  singio 
generation.  If  the  fathers  and  mothers  knew  what  it 
would  mean  to  their  children  to  be  free  from  pain  and 
mental  disturbances  caused  by  toothache,  they  would  not 
only  request,  but  demand  dental  inspection  of  the  school 
children's  teeth. 

"Seventy-five  per  cent,  of  all  contagious  diseases 
enter  the  body  through  the  mouth  and  throat,  and  untold 
thousands  of  dangerous  death  dealing  disease  germs  lurk 
in  unclean  mouths  and  decayed  hollow  teeth.  Make  it  a 
part  of  the  regular  school  work  that  the  children's  teeth 
be  inspected  twice  during  the  school  year,  and  that  they 
be  taught  the  vital  importance  of  a  clean  mouth  and  its 
relation  to  good  health  and  a  well-founded  education. 

"This  program,  if  followed  out,  will  save  human  lives. 
It  will  prevent  death  from  snatching  children  from  their 
mothers'  arms  for  the  reason  that  the  infectious  diseases 
of  childhood  lurk  and  grow  in  the  mouths  of  children 
many  weeks  after  they  have,  to  all  appearances,  re- 
covered from  a  disease.  They  return  to  school  and  play 
with  their  mates,  and  spread  disease  and  death  by  infect- 
ing other  children,  thus  emptying  the  loving  arms  of 
thousands  of  mothers  every  year,  and  instead  of  them 
having  the  God  given  privilege  of  watching  their  child- 
ren develop  into  manhood  and  womanhood,  the}^  have  now 
the  task  of  visiting  a  lonely  cemetery  and  placing  flowers 
on  a  little  green  mound,  and  return  to  a  house  that  is  not 
a  home,  but  which  only  contains  memories  of  what  might 
have  been,  and  a  mass  of  ruined  hopes. 

' '  Thousands  of  children  die  every  year  because  some 
child  who  had  been  sick  with  a  contagious  disease,  re- 
turns to  school  with  a  dirty  mouth.  Fathers  and  mothers 
of  America,  remember  this,  that  dental  inspection  in  our 
schools,  and  tooth  brushes  would  be  much  cheaper  than 
funeral  expenses   and  flowers,  and  children's  laughter 


Dental  Inspection  in  Schools.  77 

mueli  preferable  to  empty  arms  and  acliing  hearts. 
Wliicli  do  yon  prefer?  Won't  yon  start  a  campaign  in 
your  locality  for  dental  inspection  in  your  school?  The 
authorities  owe  it  to  every  child." 


CHAPTER     VI. 

FORMS  USED  IX  DENTAL  INSPECTION  AND 
CLINICS  FOR  PUBLIC  SCHOOLS. 

INSTRUCTIONS    TOR    MAKING    SCHOOL    EXAMINATION. 
DISPENSARY. THE  FORSYTH  DENTAL  INFIRMARY. 

Dental  inspection  and  record  must  preceecl  any  at- 
tempts towards  the  establishing  of  a  dental  dispensary. 
The  literature  and  forms  as  used  at  Cleveland,  Ohio,  and 
Rochester,  N.  Y.,  furnish  efficient  forms,  some  of  which 
are  illustrated. 

INSTRUCTIONS    FOR    MAKING    DENTAL    EXAMINATIONS    IN    THE 
CLEVELAND  PUBLIC   SCHOOLS. 

Examiner  should  work  in  barmonj-  with  the  principal  of  the  school  and 
should  himself  make  all  arrangements  for  the  examinations 
with  the  principal. 
Examiner  should  secure  from  the  principal  the  use  of  one  table,  two 
chairs,  Avash  basin,  hot  and  cold  water,  and  a  suitable  place 
in  which  to  keep  his  outfit  from  Aveek  to  week. 
Examiner  should  see  that  principal  undei-stands  the  instructions  for  her 
teachers,  viz  :  The  teacher  should  insert  carbon  paper  between 
the  first  two  blanks  and  then  iDroceed  to  supply  the 

School 

Date  (of  examination) 

Name  (of  pupil) 

Address   (of  pupil) 

Age  Grade  Room  No. 
for  each  pupil.  Always  in  duplicate;  aiTanged  as  the  chil- 
dren sit  in  rows  in  their  class.  The  children  should  be  sup- 
plied to  you  for  examination  in  the  same  order  in  which  the 
blanks  have  been  prepared.  Always  keep  one  or  more  of 
the  children  in  line  but  never  have  to  exceed  fives  waiting; 
one  or  more  dispels  fear,  too  may  provoke  mirth.  The 
teacher  should  not  detach  blanks.  The  blanks  should  come 
to  you  in  pad  form.  When  you  have  made  your  record, 
using  same  carbon  paper  as  teacher,  remove  the  top  sheet 
giving  this  original  to  the  pupil,  fold  over  the  pad  the  dupli- 
cate and  later  send  same  to  the  secretary  of  examinations. 


Dental,  Inspection  in  Schools. 


79 


DENTAL  EXAMINATION  OF  SCHOOL  CHILDREN,  CLEVELAND.^OHIO 
The  Cleveland  Dental  Society,  The  Ohio  State  Dental  Society  and  The  National  Dental'Association 

FRONT    OF   TEETH. 

I       a       8       4    6    0    7      8       e     10    11    la    13    14      16     10 


PER 

m 


UPPER 


Sa         31  30       29     28     27     28    26    24  23     22    21    20        19  18  17 

RIGHT  SIDE  LEFT   SIDE 

>    c 


School 

Date                      . - 

....191... 

Age Grade.. 

...Room  No 

Condition  of  Mouth 

Good 

Bad 

Condition  of  Gums 

Good 

Bad 

Use  Tooth  Brush  f 

Yes 

No 

Teeth  FHIed  ? 

Yes 

No 

Mal-occlusioli  ? 

Yes 

No 

FRONT  OF  TEMPORAIir  TECTH 


N    n     L       K 


BACK    OF   TEETH. 
8     9 


25  24 

EXPUNATION  OF  MARKS  ON  DIAGRML 
le  through  tooth  mcani  cAvity  or  CAvitie*. 


TO  PARENTS — A  sound  body  and  sound  mind  are  Csual  and  frequent  companions.  Schools  are  therefore  concerned 
with  both.  Neglect  in  care  of  the  teeth  is  the  cause  of  so  much  ill  health  that  school  authorities  everywhere  are  seeking 
co-operation  with  competent  dentists.  Our  Board  of  Education  has  arranged  with  the  local  dentists  for  a  free  examination 
of  the  teeth  of  all  school  children.    The  report  on  your  child  is  shown  above. 

This  examination  and  report  (though  not  complete)  is  not  an  attempt  to  interfere  with  your  private  matters.  -Titej 
will  bring  to  the  majority  of  tihe  parents  first  knowledge  of  the  fact  that  their  children's  teeth  need  the  attention  of  a 
dentist.  It  is  our  belief  thaj  all  parents  will  be  interested  in  having  their  regular  dentist  look  after  the  defects  pointed 
out  by  this  report.  Very  truly  yours, 

ov.i)  W.  H.  ELSON,  Superintendent  o(  Schools. 


Fig.  7. 


80  Peactical  Oral  Hygiene. 

(Back  of  card  for  dental  examiuation  of  school  children,  Cleveland,  0.) 

ABOUT  TEETH. 

Good  Teeth,  Good  Health. 
"Without  Good  Teeth  there  can  not  be  thorough 

MASTICATION. 
Without  thorough  mastication  there  can  not  he  perfect 

DIGESTION. 
AVithout  perfect  digestion  there  can  not  be  proper 

ASSIMILATION. 
AVithout  proper  assimilation  there  can  not  be 

NUTRITION. 
AVithout  nutrition  there  can  not  be 
HEALTH. 
:       Without  health  what  is 
LIFE? 

Number  of  Teeth:. 
There  are  twenty  teeth  in  the  first  or  temporaiy  set — 10  upper  and 
10  lower.  In  the  permanent  or  second  set  there  are  32  teeth — 16  upper 
and  16  lower. 

Their  Purpose. 
The  teeth  are  for  ornamentation,  for  grinding  the  food,   (thus  pre- 
paring it  for  proper  digestion),  and  assistance  in  talking.     They  should 
last  to  the  end  of  life. 

How  Lost. 
By  decay  and  loosening.    Decay  is  caused  by  allowing  food  to  remain 
about  the  teeth  and  by  poor  health.     Teeth  become  loose  by  a  deposit  on 
thern  at  the  edge  of  the  gum,  called  tartar. 

How  Can  Decayed  Teeth  and  Diseased  Gums  be  Prevented*? 
By  cleaning  the  teeth  with  a  tooth  brush  and  water  on  arising  in 
the  morning  and  before  going  to  bed  at  night.    A  quill  toothpick  prop- 
erly sharpened,  should  be  used  after  each  meal.     A  toothpowder  used 
on  the  brush  will  assist  in  cleansing  the  teeth. 

The  essential  ingredient  in  all  good  tooth  powders  is  precipitated 
chalk.  This  may  be  flavored  to  suite  the  taste.  The  following  formula 
is  considered  a  good  one : 

Precipitated  Chalk    SVz  ounces. 

Pulverized  Castile  Soap   %       " 

Garantos 1      grain. 

Flavor  with  Oil  of  Peppermint, 

Sassafras,  Wintergreen  or  Cinnamon  ...   5      drops. 
The  slow  and  thorough  chewing  of  the  food  helps  to  preserve  the 
teeth  and  keep  the  mouth  in  a  healthy  condition. 

Evei'y  person  should  have  his  leeth  examined  l)y  a  competent  devitist 
several  times  a  year. 

Cleanliness  is  the  best  2'uard  acainst  disease. 


Dental  iNSPECTioisr  iisr  Schools.  81 

You  will  find  that  one  bundi'ed  examiuations  will  be  all  that 
you  can  care  for  in  one  moniing  of  thi'ee  hours  until  you 
have  had  some  experience.  There  will  be  sent  to  each  school 
with  examination  blanks,  four  carbon  papers  so  that  four 
teachers  may  prepare  for  coming  examinations  at  the  same 
time.  These  carbon  papers  should  be  left  by  the  teacher  in 
the  pad  of  blanks.  You  Avill  need  them  for  your  work. 
When  you  have  finished  examining  for  the  day,  be  sure  to 
return  the  four  carbon  papers  to  the  principal  for  future 
use. 

Examiner  should  be  prompt  in  attendance. 

Examiner  should  have  his  person  neat  (wear  office  coat)  and  above  all 
his  hands  and  nails  should  be  mechanically  clean.  He  should 
see  that  his  mouth  is  clean  as  an  example,  and  his  breath 
should  be  sweet. 

Examiner  must  not  use  tobacco  w-hen  on  school  jDroperty. 

Examiner  should  use  a  pad  of  blanks  for  each  room. 

Examiner  should  examine  with  his  back  toward  a  window,  that  he  may 
have  good  direct  light  in  the  pupil's  mouth. 

Examiner  must  keep  his  hands  out  of  pupil's  mouth. 

Examiner  must  not  use  any  instrument  except  a  mouth  mirror. 

Examiner  must  not  use  a  mirror  but  once  until  resterilized. 

Examiner  should  see  that  vessels  containing  carbolic  acid  and  alcohol 
are  labeled  at  all  times. 

Examiner  should  see  that  sterilizing  is  properlj-  done  and  that  miiTors 
are  free  from  both  carbolic  acid  and  alcohol  and  are  at  a 
temperature  that  will  be  comfortable  to  the  mouth  and  not 
fog  the  glass.  This  will  necessitate  frequent  change  of  hot 
water  in  the  last  glass.  Proper  sterlization  of  miiTors  for 
this  work  will  consist  in  :  1st.  "Wiashing  Avith  a  brush,  in  hot 
water  and  soap.  2d,  Immersion  in  carbolic  acid  solution  (as 
provided  which  is  1  to  64)  for  at  least  five  minutes.  3d. 
Immersion  in  alcohol  (95%)  (alcohol  must  be  at  least  one- 
half  inch  deeper  than  carbolic  solution).  4th,  Immersion 
in  hot  water  until  used.  This  water  should  be  changed  at 
least  once  for  every  thirty  mirrors  passed  thru  it.  jMiiTors 
should  be  used  wet  and  not  touched  with  the  hand,  napkin 
or  othei-wise. 

Examiner  should  always  leave  his  outfit  clean  and  as  nearly  ready  for 
use  as  possible.  Carbolic  acid  solution  and  alcohol  should 
be  thrown  into  sewer  at  close  of  day's  work. 

Examiner  must  proAade:  Six  (6)  miiTors  (Ash  miiTors  may  be  had  for 
50c  each  or  6  for  $2.50,  at  Ransom  and  Randolph's.)  Three 
large  drinking  glasses  for  alcohol,  carbolic  acid,  and  water. 
Six    (6)    pencils.     Towels   for  personal   use.     Soap.    Basin 


82 


Peactical  (3ral  Hygiene. 


and  Inrush  for  scrubbing  uiiri'ors.     One  tray  to  receive  soiled 
niirrois.     An  assistant  to  sterilize  the  mirrors. 


Fig.  S.     Proper  Arraxgemext  of  Tap.le  for  School  Ixspectiox 

Work. 

Examiner  will  be  furnished  with  a  card  of  appointment  which  he 
should  carry  on  his  person. 

Examination  blanks,  alcohol,  carbolic  acid,  and  labels  for  the 
same  will  be  furnished  and  ^^'ill  be  delivered  to  the  principal 
of  the  school. 

The  Oral  Hygiene  Committee  will  pay  assistants  at  the  rate 
of  oOe  per  half  day  which  means  three  hours  work. 
Should  examiner  be  unable  to  provide  an  assistant,  one  Avill 
be  furnished  him  upon  request. 
Do  not  examine  Kindergartens. 

Examine  1st  grades  first,  and  8th  grades  last.     Never  force 
a  child  to  submit  to  examination  if  parents  object.     If  par- 
ents object,  so  mark  his  chart  and  send  original  home. 
If  child  is  afraid  have  him  first  see  you  examine  another, 
after  Avhich  you  will  have  no  trouble. 

detail  of  a  day^s  work. 

Examiner  and  his  assistant  should  be  at  the  school  at  S  :15  A.  M.  and 
should  at  once  notify  the  principal  that  he  will  be  readj-  for 
work  at  8:30. 

Examiner  and  his  assistant  should  prepare  his  table  after  the  fashion 
shown  in  the  enclosed  blue  print.  Begin  work  promi3tly  and 
continue  steadily  until  recess  at  which  time  a  few  minutes 
relaxation  in  the  fresh  air  will  be  found  beneficial.  After 
recess  resume  work  until  close  of  morning  session. 
Have  assistant  clean  and  store  all  utensils  properly.  Make 
out  your  report  and  wrap  with  pads  of  examinations.  Pay 
your  assistant;  the  society  will  i^ay  you.     Have  her  receipt 


Dextal  Inspectioi^  IX  Schools.  83 

for  it  on  your  report.  Inform  j-our  principal  of  your  next 
appearance  and  depart.  In  most  convenient  manner  send 
your  report  and  blanks  to  the  seeretai-y  of  Examinations. 
Should  you  need  any  supplies  notify  See'y  of  Exams  at  once. 
Call  Main  517. 
Examiner  should  not  ask  ]uipil  if  he  has  a  family  dentist. 

DISPENSAEY. 

In  Chicago,  it  took  six  months  of  constant  work  to 
secure  the  consent  and  approval  of  the  Department  of 
Health  for  a  Dental  Dispensary  for  children.  This,  in 
the  face  of  a  free  offer  of  equipment,  and  means  of  main- 
taining it. 

One  of  the  first  requirements  in  establishing  a  dispen- 
sary is  to  eliminate  those  who  are  not  entitled  to  free 
dispensary  care.  This  is  accomplished  by  having  the 
parents  of  the  ^Datient  sign  a  card  authorizing  the  ser- 
vices which  is  so  worded  as  to  eliminate  the  well-to-do 
child. 

DISPENSAEY  PLAN. 

In  the  carrying  forward  of  the  work,  various  opera- 
tors may  have  to  handle  a  case  before  it  is  finished.  As 
every  dentist  has  some  pet  way  of  doing  things,  it  is  first 
essential  to  establish  and  tabulate  on  printed  card  a 
routine  series  of  treatments.  Thus  the  patient  can  be 
carried  through  any  treatment  with  several  operators 
without  any  hesitation  or  embarassment  of  either 
operator. 

The  operation  of  free  clinics  for  dental  service  is  dis- 
cussed here  solely  for  the  reason  that  they  can  be  made 
the  greatest  factor  for  oral  hygiene  teaching.  The  ques- 
tion has  arisen  that  this  part  of  the  work  and  the  great 
opportunity  it  affords  is  often  neglected. 

Dr.  N.  S.  Hoff  has  called  our  attention  to  the  statistics 
of  the  various  dental  clinics  criticising  the  reports  be- 
cause they  show  such  a  small  number  of  operations  under 
the  head  of  "cleaning  teeth,"  as  compared  with  other 
work  done.     His  suggestion  is  that  every  patient  pre- 


84 


Peactical  Oral,  Hygiene. 


Rochester  Dental  Society — Free  Dental  Dispensaries 

OClIITord,   Thomas   and  \Veeger   Streets 
School   No.  '20 


Scto   St.   cor.   University   Ave. 
School    No.    14 

IMame     .J\A.0LnrA4  .  .^  O^A^VS^A  .  . 
Address     .'.  X.  .  VtM/lAAir-l? .  .*J .  •. 


0~32  S.  Washington  Street 
Uoehe 


■  enter  I'ublle  Health  Ansu. 


No.  In  family 


Income 


'^/.0">. 


Employer     U^  ;  %..  A/M-frV^ 
^2   6-"^      .<r       ^(^ 


M. 


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Rent     . O 

School    No 

Se 

SlKnsiture    of    I'arent    or    Guardian 

ALWAYS   BRING  THIS   CARD  WITH  YOU 


fnt    by    .IV"^.  .U...^S-r^^Vr.  . 


Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

h/7 

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"(over) 


PENALTY  FOR  FALSE  REPRESENTATIONS. 

Section  25,  Chapter  368,  Laws  of  1899. 


Any  jDerson  who  obtains  medical  or  surgical  treatment  on 
false  representations  from  any  dispensary  licensed  nnder  the 
provisions  of  this  act,  shall  be  guilty  of  a  misdemeanor,  and 
on  conviction  thereof  shall  be  punished  by  a  fine  of  not  less 
than  ten  dollars  and  not  more  than  two  hundred  and  fifty 
dollars. 

(Imprisonment  until  fine  be  joaid  may  be  imj^osed.  Code 
Crim.  Pro.  Section  718.) 

Fig.  11.    Rochester  Dispensary  Card. 

sent  should  have  his  teeth  cleaned  thoroughly,  and  should 
be  instructed  in  oral  hygiene.  Says  Dr.  Hoff,  in  an  edi- 
torial in  the  Denial  Dhpensarij,  August,  1912,  ''It  would 
seem  that  nine-tenths  of  the  time  and  energy  of  the  den- 
tists in  charge  of  these  clinics  had  been  expended  in 
relieving  the  pain  of  diseased  teeth,  and  repairing  the 
loss  of  tooth  substance.    We  are  justified)  in  say'mg  that 


Feee  Dental  Disjeis^sary. 


85 


ROCHESTER     DENTAL    SOCIETY  —  FREE     DENTAL    DISPENSARY     No.    2 
Card  of  admission  on  representation  or  statement  of  patient. 


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Remarks 

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This  Is  my  _i application  to  this  Dispensary  In  the  year ^^  ^  ^ 

the  year    V^V  t^     (or  to  the  following  Dispensaries)        *^^^.~*->aA^    ~^  t./^.^^Jt|ftA  —    ^^    ZJLt 
The  foregoing  statement  Is  In  all  respects  trus; 

Signature  of  applicant  /^>r-X .    ^^ <    ^     A7.-'*^l-VL<^g/ . 


been  an  applicant  to  no  other  Dispensary  in 


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Fig.  10.    Back  of  Card  of  Adimissiok. 


86  Peactical,  Oeal  Hygiene. 

RECORD  OF  EXAMINATION  OF  THE  MOUTH. 
(Suggested  by  Dr.  Hunt.) 

CUT    OP    TEETH  Scbool      

Date    •  • 

UPPER  TEETH.  Name     

Address    


A      line      drawn  .  ^, 

■  1  ,  J-     J.1  Age Orac  e 

through       a       tootn      *=  ,  r^-,     -,  •. 

-,  (Cheek  one) 

means    a    cavity    or  ^^      _^.         n^r     ^i  ^^      -,     -r^  ■      -J.    -, 

.,.  Condition  of  Mouth  Good     Fair     Bad 

■cavities.  ,,  _        ,^       . 

Abscesses,  How  Many  1 

0    around    tooth  Teeth  Need  Cleaning?     Yes.     No. 

means  crown  is  lost.  Use  Tooth  Brush?  "Ycs.     No. 

X     across     tooth  ^/^  ^f'*!'  ^'^^^     If'     ^'°- 

means        pea-manent  Malocclusion?     les.     No. 

tooth  lost.  K^™^^-^^^    


LOWER   TEETH.  

Care  op  the  Mouth. — ^^To  keep  off  tartar  aud.  have  better  health, 
chew  every  bit  of  food  twice  as  much  as  you  have  been.  Clean  the 
teeth  every  morning  before  breakfast  and  at  bedtime.  The  last  is 
very  important.  If  you  have  no  other  tooth  powder  you  can  get  a 
good  deal  of  precipitated  chalk  at  the  drug  store  for  five  cents.  The 
teeth  should  be  brushed  by  placing  them  end  to  end  and  brushing  them 
in  an  up  and  down  direction,  letting  the  brush  go  well  up  on  the  gums 
in  both  jaws.  This  should  be  done  on  the  outer  surfaces  of  all  the 
teeth.  Then  open  the  mouth  and  brush  the  giinding  surfaces  hard, 
being  careful  to  go  clear  back  to  the  last  teeth.  Then  tilt  the  brush 
and  scrub  the  inner  surfaces  of  all  the  teeth,  letting  the  brush  go  up 
■on  the  gaims.  Then  stick  out  your  tongue  and  brush  the  top  of  it.  You 
cannot  injure  the  gums  by  brushing  them  up  and  down.     It  does  them 


To  Parents. — 'In  making  this  examination  for  your  child  at  no 
cost  to  you,  there  was  no  desire  to  interfere  with  your  private  affairs. 
We  are  sure  you  will  be  glad  to  knoAv  the  condition  of  the  moutli.  We 
hope  you  ■will  take  the  child  to  a  dentist  and  have  all  necessary  repairs 
and  cleanings  made.  It  may  be  the  dentist  will  find  ot].ier  cavities. 
Our  examination  was  not  meant  to  be  thorough  as  our  time  was  limited. 

A  healthy  mouth  means  better  chewing  of  food;  better  chewing  of 
the  food  means  better  digestion  of  it;  better  digestion  means  better 
health ;  lietter  health  means  a  strongr,  abler  child,  greater  freedom  from 
diseases  and  better  school  Avork.  Give  your  ehild  all  the  chance  yo  ucan 
to  oTow  up  healthy  and  with  a  good  education. 

Very  truly  yours, 

Superintendent  op  Schools. 


88  Peactical  Okal  Hygiene. 

the  amount  of  real  hygiene  instruction  given  in  these 
clinics  is  far  short  of  ivhat  it  should  he,  for  tlie  expense 
of  money  and  sacrifice  of  time  put  into  it  by  professional 
men,  of  course  actual  repair  and  relief  operations  must 
be  made,  but  tlie  chief  aim  of  these  clinics  ought  to  be 
to  impart  instruction  that  will  help  these  children  place 
the  proper  value  on  their  teeth,  and  compel  them  to  give 
some  measure  of  attention  in  the  way  of  a  systematic 
mouth  toilet." 

This  view  is  correct,  and  it  is  to  be  hoped  those  who 
have  such  work  in  charge  will  realize  the  facts,  and  take 
advantage  of  their  great  opportunity  for  spreading  the 
gospel  of  clean  teeth. 

THE  NEW  FOKSYTHE  FREE  DENTAL  INFIRMARY. 

The  Dental  Infirmary  erected  in  Boston,  and  dedi- 
cated to  the  needs  of  children  is  now  the  model  insti- 
tution for  all  the  world. 

The  site  and  building  cost  half  a  million  dollars,  and 
is  endowed  with  $1,000,000.00  for  its  maintenance.  It  is 
equipped  with  the  latest  and  best  dental  equipment,  in- 
cluding a  lecture  hall  for  the  teaching  of  oral  hygiene  to 
the  public.  The  institution  is  doing  what  the  trustees 
started  out  to  accomplish,  that  is  an  aid  for  "A  better 
looking,  more  perfectly  developed  race." 

Dr.  G.  W.  Clapp,  by  editorial  in  the  Dental  Digest, 
thus  discusses  the  oral  conditions  in  their  relation  to 
community  hygiene,  writes : 

"In  America  we  have  not  yet  reached  so  enlightened 
a  condition;  our  oral  hygiene  clinics  are  mostl}^  con- 
ducted as  charities  by  the  efforts  of  a  few  noble-minded 
practitioners  and  the  aid  they  solicit.  In  the  light  of  ex- 
perience here  and  abroad  it  is  probably  safe  to  say  that 
this  is  neither  a  just,  a  wise,  or  a  safe  foundation  for 
such  enterprises,  save  in  instances  like  the  Forsythe  In- 
firmary, where  a  great  endowment  insures  permanency 
and  adequate  equipment.   Community  oral  hygiene  is  not 


o 

c 


o 


^ 


90  Peactical  Oeal  Hygiene. 

the  burden  of  the  dental  profession.  It  may  be  our  duty 
to^  prove  its  merits,  to  show  what  it  can  do  for  the  com- 
munity and  to  assist  in  its  establishment  by  all  the  means 
in  our  power.  But  to  look  forward  to  its  permanent  con- 
duct by  dentists  is  to  insure  that  it  will  fail  of  its  great- 
est usefulness. 

'' Community  oral  hygiene  is  of  right  a  community 
enterprise.  It  has  more  to  do  with  the  health  of  the  per- 
sons comprising  the  community,  with  their  economic 
efficiency  and  the  return  which  they  shall  make  to  the 
community,  than  almost  any  other  single  measure.  In 
the  minds  of  those  who  have  studied  it  most,  it  will  i3rove 
an  economy  rather  than  an  expense.  It  is  not  impossible 
that  within  the  childhood  of  those  who  benefit  by  it,  it  will 
save  its  cash  cost  to  the  community  in  freedom  from  dis- 
ease, in  improved  attendance  of  children  at  school,  in 
greatly  improved  mental  ability,  and  in  reforming  juve- 
nile criminals." 


C  H  A  P  T  E  E  Yll. 

TUBEECULOSIS  AND  THE  OEAL 
HYGIENE  MOVEMENT. 

As  lias  been  pointed  out  again  and  again,  one  of  the 
greatest  fields  of  dental'  work  is  that  of  preventive  den- 
tistry; from  the  present  trend  of  medical  science,  it  ap- 
pears that  an  important  branch  of  this  work  in  the  future 
will  be  that  of  aiding  in  the  fight  on  the  "Great  White 
Plague."  Observations  have  shown  me  that  the  vast. ma- 
jority of  patients  who  have  contracted  tuberculosis,  have 
unclean  mouths,  and,  on  the  other  hand,  I  believe  the 
patient  with  the  well-cared-for  mouth  is  better  able  to 
resist  this  infection. 

The  only  successful  treatment  so  far,  depends  on  the 
use  of  fresh  air,  plenty  of  good  food,  pure  water,  and 
rest.  The  most  important  of  these  is  proper  feeding,  and 
jDroper  feeding  depends  on  proper  mastication.  Com- 
plete and  proper  mastication  cannot  be  accomplished  un- 
less the  patient's  mouth  is  in  a  healthy  conditioai. 
Ulcerated  teeth,  flowing  pus  from  pockets,  exposed  pulps 
in  teeth,  and  two-thirds  of  the  teeth  out  of  the  jaw  or  out 
of  service,  will  not  give  the  proper  nutrition  even  from 
the  purest  foods  obtainable. 

The  pure  air  of  a  pine  forest,  passing  through  a  sep- 
tic mouth,  is  no  better  than  tlie  air  of  a  crowded  tene- 
ment. 

Statistics  show  that  fully  seventy  per  cent,  of  school 
children  have  enlarged  glands.  This  means  either  a  form 
of  tuberculosis  or  else  a  predisposition  towards  that  dis- 
ease. A  large  per  cent,  of  these  cannot  have  other  than 
dental  entrance  for  these  poisons,  for  most  of  them  have 
open  root  canals.  This  has  been  demonstrated  before  the 
German  Surgical  Society  by  the  process  of  innoculating 
the  pulps  of  children's  teeth. 


92  Practical  Oeal  Hygiej^e. 

In  the  crusade  against  the  ''Great  White  Plague," 
there  is  not  enough  stress  being  laid  on  the  question  of 
oral  sepsis  as  a  causitive  factor  for  this  disease,  nor  is 
importance  enough  attached  to  its  worth  towards  a  cure 
of  these  patients.  This  matter  should  be  brought  to  the 
attention  of  the  heads  of  the  various  institutions  which 
treat  tubercular  conditions,  and  also  the  authorities  who 
control  the  charity  institutions.  It  is  our  duty  to  con- 
vince these  people  of  the  great  benefits  that  dentistry  can 
accomplish  for  those  under  their  care. 

A  few  years  ago,  the  writer  became  interested  in  a 
free  dental  clinic  for  the  "Anti-Tuberculosis  Society"  of 
Atlanta,  which  was  operating  a  free  medical  clinic.  He 
brought  the  matter  before  the  Medical  Society,  and 
then  the  Dental  Society,  finally  securing  the  equip- 
ment for  running  the  clinic.  At  first  the  members 
of  the  Atlanta  Dental  Society  took  up  the  work 
at  stated  intervals.  At  the  present  time  the  Society 
has  a  regular  clinician  of  stated  salary  to  do  this 
work.  Reports  show  a  great  number  of  filling  operations 
with  a  very  small  per  cent,  of  oral  hygiene  treatments. 
This  criticism,  of  course,  applies  not  only  to  this  clinic, 
but  to  all  others  of  this  kind  that  have  come  under  the 
writer's  investigation.  Not  long  ago  Dr.  Hoff  criticised 
a  report  of  a  similar  case  in  like  manner.  I  hope  that  in 
the  future,  those  who  have  these  institutions  under  man- 
agement, will  bear  in  mind  that  the  stressing  of  oral 
hygiene  is  of  more  joractical  value  than  dental  restora- 
tion to  the  patients.  This  is  not  meant  to  discourage 
dental  work,  but  it  should  be,  undoubtedly,  made  secon- 
dary, while  it  is  at  present  primary.  Every  patient  who 
presents  for  dental  attention,  should  have  his  mouth 
thoroughly  saturated  with  some  solution.  The  clinician 
should  not  examine  the  patient's  mouth  until  this  has 
been  done.  Each  one  of  these  patients  should  have  his 
teeth  cleaned  up  and  treated  with  Iodine  solutions  until 
oral  sepsis  conditions  are  cured.  Not  only  this,  but  every 
one  of  them  sbould  be  instructed  in  the  use  of  the  tooth 


Tuberculosis  and  Oral  Hygiene.  93 

brush,  and  made  to  show  improvement  in  mouth  condi- 
tions. The  method  adopted  in  reference  to  tooth  brushes 
in  Atlanta  is  to  buy  seconds  from  the  tooth  brush  manu- 
facturers, and  sell  them  to  the  jjatients  at  cost. 

In  clinics,  which  I  have  visited,  I  noticed  that  in  the 
medical  room  there  are  always  charts  and  pictures,  show- 
ing the  patients  what  and  how  to  eat,  and  how  to  take 
care  of  themselves.  In  the  dental  clinic  a  like  method 
should  teach  them  how  and  why  they  should  keep  their 
mouths  clean.  It  is  now  known  that  more  trouble  comes 
from  septic  mouths  than  from  dental  caries.  I  have  fre- 
quently noticed  that  these  septic  mouths  do  not  present 
as  large  an  amount  of  caries  as  do  mouths  under  normal 
conditions.  Cards  should  be  distributed  in  the  dental 
clinic,  calling  attention  to  the  importance  of  this  fact, 
also  cards  explaining  the  proper  use  of  tooth  brush,  and 
dentifrice  cream,  should  be  given  to  the  patient.  If  this 
take  all  of  the  time  of  the  clinician,  then  the  dental  col- 
leges and  other  clinics  of  like  nature  would  be  only  too 
glad  to  get  the  regular  dental  work  to  do.  It  takes  an 
expert  to  handle  the  oral  hygiene  part  of  the  work  at  this 
kind  of  clinic.  If  our  dentists  could  only  see  the  matter 
in  this  light,  and  quit  paying  all  their  attention  to  filling 
teeth,  I  believe  that  the  medical  men  would  soon  rally  to 
the  cause  and  place  in  every  institution  dentists  to  do  this 
kind  of  work.  "\¥h.ile  there  are  medical  authorities  who 
recog-nize,  to  the  fullest  extent,  the  importance  of  this 
matter,  not  until  it  is  generally  recognized  will  the  con- 
dition improve  as  it  should. 

Drs.  Weidmann  and  Lubowski  say : 

' '  There  is  no  disease  in  which  healthy  and  clean  con- 
ditions of  the  mouth  are  of  such  vital  importance  as  in 
tuberculosis  of  the  lungs.  Tubercle  bacilli  are  found  in 
carious  cavities,  and  it  has  been  proved  that  especially 
unclean  portions  of  the  mouth  constitute  a  portal  of  en- 
trance for  the  tubercular  poison.  Partsch,  of  Breslau, 
reports  a  case  of  grave  tuberculosis  caused  by  a  carious 
tooth  with  such  acute  inflammation  of  the  lymphatic  ves- 


94  Peactical  Oeal  Hygiene. 

sels  that  an  operation  became  necessary.  Also  many 
cases  of  tuberculous  infection  by  way  of  the  alveoli  have 
been  reported.  These  and  the  authors'  own  observations 
leave  no  doubt  as  to  the  fact  that  dental  caries  is  respon- 
sible for  many  cases  of  tuberculosis.  Tuberculous 
tumors  situated  opposite  carious  teeth  resist  every  treat- 
ment until  the  carious  teeth  are  filled  or  extracted.  Long- 
established  lymphatic  swellings  also  will  generally  not 
yield  until  the  carious  teeth  are  treated.  All  the  gener- 
ous efforts  of  charitable  and  public  institutions  for  the 
cure  or  prevention  of  tuberculosis  are  of  no  avail  unless 
the  causes  of  the  disease  are  removed,  and  among  the 
most  dangerous  causes  are  beyond  doubt  defective  teeth 
and  unhygenic  oral  conditions  which  exist  especially  in 
children. ' ' 

S.  Adolph  Knoph,  Professor  of  Phthisio-Therapy  at 
the  New  York  Post  Graduate  Medical  School  and  Hos- 
pital, of  New  York,  writes : 

"It  must  be  said  to  the  glory  of  the  American  achieve- 
ments that  dental  science,  the  art  of  preserving  the  teeth 
by  truly  scientific  method,  had  its  birth  in  this  country. 
While  we  physicians  have  gone  to  Europe  to  complete 
our  education,  the  European  dentist  comes  to  America 
to  learn  the  best  and  latest  in  his  profession.  The  latest 
and  most  glorious  development  of  the  American  dental 
science  is  dental  hygiene,  for  dental  hygiene  means  pre- 
vention and  preservation,  and  these  bear  the  closest  re- 
lation to  the  prevention  of  tuberculosis. 

''One  of  the  earliest  and  very  frequnet  symptoms  of 
tuberculosis  is  impaired  digestion.  While  I  do  not  wish 
to  say  that  bad  teeth  constitute  the  onl}^  cause  of  diges- 
tive disturbance,  if  bad  teeth  are  present,  they  are  a  fac- 
tor contributing  to  this  pathogenic  condition.  Ulcerated 
teeth  may  give  entrance  into  the  bone  of  tubercle  bacilli 
that  have  been  accidentally  inhaled  or  have  been  con- 
tracted by  secondary  infection." 

Prof.  Fisher,  of  Yale,  is  authority  for  the  statement 
that,  ''Seventy-two  Americans  die  every  hour  from  pre- 


Tuberculosis  and  Oral  Hygiexe,  95 

veritable  diseases."  Counting  this  up  for  a  year,  we  are 
amazed  at  the  glaring  fact  of  this  needless  mortality 
which  "^e  have  here  in  our  country.  Enough  people 
might  be  saved  each  year  to  populate  a  city  the  size  of 
Baltimore,  and  the  further  fact  is  that  at  any  time  these 
deaths  may  come  near  to  our  o^vn  doors.  A  large'  per 
cent,  of  these  deaths  come  from  dental  origin,  and  makes 
it  necessary  for  the  dental  profession  to  "sit  up  and  take 
notice." 

Drs.  W.  Gr.  Ebersole  and  Marshall  have  declared  that 
decay  of  the  teetli  is  the  most  prevalent  disease  of  dvi- 
lization,  and  that  there  are  thousands  of  invalids  who  are 
such  because  of  faulty  oral  conditions.  They  also  believe 
that  all  the  medical  treatment  in  Christendom  could  not 
cure  them.  It  is  not  for  the  dental  profession  nor 
the  medical  profession  to  claim  the  whole  field  for  the 
work,  and,  even  together,  we  can  hardly  make  a  success- 
ful fight  unless  the  sympathies  of  the  people  are  gained, 
and  they  work  with  us  against  the  great  common  foe — the 
"Preventable  Diseases." 


CHAP  TEE     VIII. 
BRUSHING  THE  TEETH. 

SHAPE  OF  THE  BRUSH. TEACHING  THE  TECHNIQUE  OP  BRUSH- 
ING   THE    TEETH. THE    DIRECTION    CARD. THE    BAD 

BREATH  SIGNAL. LIME  WATER  AS  A  MOUTH  WASH. 

Tooth  brush  handles  at  the  present  tune  are  made  of 
bone,  purchased  from  the  Chicago  Stock  Yards.  The 
best  grade  handles  are  made  from  the  thigh,  and  the 
cheaper  ones  are  made  from  the  shin  and  buttocks  bone. 
The  back  is  grooved,  holes  are  drilled,  and  then  wire  is 
drawn  through,  pulling  the  bristles  into  place.  The 
grooves  are  then  filled  with  cement. 

The  best  bristles  come  from  Russia,  India,  and  G-er- 
many.  They  are  washed,  bleached,  cut  into  proper  size, 
selected,  and  graded.  In  one  tooth  brush  factory,  I  am 
informed,  that  some  of  the  graders  have  been  employed 
for  twenty  years  at  the  same  work. 

SHAPE    OP    BRUSH. 

As  to  the  shape  of  the  brush,  we  have  every  variety 
described,  from  the  sway-backed  brush  to  its  opposite, 
the  curved  handled  brush  in  the  so-called  "Prophylactic 
Tooth  Brush."  In  shape  they  vary  from  the  largest,  as 
prescribed  by  Dr.  D.  D.  Smith,  to  the  smallest  one,  de- 
scribed by  Dr.  Jules  J.  Sarrazin,  of  New  Orleans.  In 
"texture,  they  range  from  the  softest  brush,  prescribed 
by  the  author,  to  the  stiifest  brush,  prescribed  by  many 
of  the  leaders  of  the  profession.  Each  dentist  has  some 
peculiar  idea  upon  the  shape  and  size  of  the^  brush,  but 
this  will  have  little  bearing  upon  the  subject  as  to  clean- 
ing the  teeth. 

TEACHING  THE  TECHNIQUE   OP  BRUSHING  THE  TEETH. 

There  is,  however,  one  point  upon  which  they  will  all 
agree,  and  that  is  the  training  of  the  patient  into  the 


Bkuseeing  the  Teeth.  97 

proper  brushing  of  the  teeth.  It  is  surprising  to  note  the 
ignorance  of  our  best  patients  upon  the  handling  of  the 
tooth  brush.  It  is  even  more  surprising  to  note  how  few 
dentists  take  any  time  to  train  these  j)atients.  I  have 
made  it  a  point  to  inquire  always  of  new  patients  whether 
or  not  their  former  dentists  taught  them  to  use  the  tooth 
brush  properly.  Very  seldom  do  they  answer  in  the 
affirmative.  However,  asking  the  question,  m  most  cases, 
is  superfluous.  The  appearance  of  the  teeth  tells  us  all 
that  we  want  to  know. 

It  is  a  good  idea  to  have  brushes  in  the  office  for  sale 
to  our  patients,  for,  if  we  give  them  a  prescription,  they 
go  to  the  drug  store,  and  do  not  always  get  the  proper 
brush,  and  we  do  not  have  the  chance  of  teaching  them 
to  brush  the  teeth  properly.  It  is  a  good  idea  to  buy  the 
best  brushes  obtainable,  by  the  gross,  and  allow  the  office 
assistant  to  handle  the  sale  of  them.  Incidentally,  there 
might  be  added  all  the  articles  for  the  proper  toilet  of 
the  mouth,  such  as  floss  silk,  dentifrice,  and  mouth  wash. 
People  do  not  buy  brushes  enough.  They  will  use  them 
until  they  are  worn  almost  to  the  handle.  Such  a  brush 
is  not  only  laden  with  germs  of  all  kinds,  but  it  is  abso- 
lutely worse  than  nothing  with  which  to  brush  the  teeth. 
Such  a  brush  is  always  shedding  its  bristles,  which  stick 
between  the  teeth  and  cause  great  irritation. 

Dr.  C.  Eclmund  Kells,  of  New  Orleans,  was  the  first 
man  to  give  me  the  idea  of  having  ' '  Direction  Cards ' '  for 
brushing  the  teeth,  for  ' '  distribution  among  the  patients 
when  the  brush  is  sold  to  them."  A  modification  of  the 
Kells  card,  as  used  by  myself,  is  here  shown.  If  we  give 
the  patient  these  directions  orally,  he  soon  forgets,  but  if 
we  give  them  to  him  on  a  printed  card,  it  is  impressed 
on  his  mind. 

Some  years  ago,  I  had  a  patient,  an  elderly  lady,  for 
whom  I  did  a  great  deal  of  work.  "When  the  work  was 
finished  I  explained  to  her  that,  at  her  age,  she  could  not 
expect  the  work  to  last  as  it  should  unless  she  brushed 
her  teeth  properly.    At  this  time,  I  did  not  keep  brushes 


98  Practical  Oeal,  Hygiene. 

for  sale  in  the  office,  and  told  lier  to  go  to  the  drug  store 
and  purchase  a  certain  kind  of  tooth  brush  and  to  brush 
her  teeth  correctly.  Some  months  later,  I  received  a  long-^ 
distance  telephone  message  that  the  work  had  entireh^ 
given  out,  and  that  her  mouth  was  in  a  terrible  and  pain- 
ful condition.  An  engagement  was  made.  On  her  ar- 
rival, I  found  that  the  condition  was  about  as  she  had 
said.  Of  course,  she  had  been  brushing  her  teeth,  ''just 
as  3^ou  told  me.  Doctor."  She  was  rather  wrathy. 
Arrangements  were  made  for  the  patient  to  come  next 
day,  and  bring  her  brush  with  her.  The  next  day  she 
returned,  and  I  had  her  to  brush  her  teeth  for  me.  She 
brushed  the  teeth  as  well  as  I  or  anybody  else  could  have 
done  it,  but,  if  she  had  been  taught  for  a  month,  she  could 
not  have  evaded  more  skilfully  the  very  places  which  she 
needed  to  brush,  that  is,  the  gingival  margin  of  the  gums. 
This  led  me  to  the  valuable  idea  of  never  saying,  "brush 
the  teeth,"  but  rather  say,  ''brush  the  gums,"  for  if  they 
brush  the  gums  in  a  proper  manner,  the  teeth  will  get 
a  thorough  brushing. 

In  demonstrating  the  brushing  to  the  patient,  there 
are  several  methods  which  may  be  employed.  The  one 
advocated  and  used  by  Dr.  Edmund  Kells,  and  Dr.  R.  B. 
Adair,  is  that  of  having  a  full  artificial  denture,  and 
demonstrating  to  the  patient  by  brushing  this  model. 
However,  I  find  it  more  efficient  to  have  the  patient  hold 
a  hand  mirror,  and  watch  me  brush  their  own  teeth  in  the 
proper  manner.  A  peculiar  fact  is,  however,  that,  while' 
you  are  brushing  the  patient's  teeth,  and  trying  to  show 
him  what  you  are  doing,  his  eyes  are  over  the  edge  of  the 
glass  or  off  to  one  side,  anywhere  except  on  the  mirror. 
You  will  have  to  look  in  the  glass  as  well  as  at  the  teeth. 
They  will  tell  you,  "Yes,  I  understand,  I  see,"  when  they 
are  not  seeing  at  all.  Be  careful  about  this  point,  and 
make  them  see.  When  you  have  finished  the  demonstra- 
tion, give  them  a  brush,  and  make  them  go  over  it  them- 
selves.    I  sometimes  have  the  patient  hold  the  brush. 


Brushing  the  Teeth.  99' 

while  I  grasp  their  fingers  in  order  to  make  them  go 
through  the  proper  manipulations. 

I  remember  one  patient,  a  prominent  physician  in  an 
adjoining  state,  who  I  had  remain  for  a  week,  visiting  my 
office  daily,  taking  some  six  or  seven  lessons  before  he 
had  mastered  the  technique  of  brushing  his  teeth.  It  is 
a  lamentable  fact  that  so  few  people  possess  enough 
manual  dexterity  to  touch  all  the  surfaces  of  their  teeth. 

Personally,  I  believe  in  a  soft  grade  of  tooth  brush, 
for  the  reason  that  the  gums  are  massaged  with  the  sides- 
of  the  bristles;  should  this  be  done  with  a  stiff  bristle 
brush,  it  would  do  considerable  damage,  that  is,  if  the 
patient  carried  out  my  instructions.  Again,  I  know  that 
a  soft  bristle  brush  is  sufficient  to  clean  and  polish  the 
surfaces  of  the  teeth.  I  know,  that  whenever  I  want  to 
polish  anything  on  my  lathe,  I  use  wheels  of  fine  texture, 
and,  that  whenever  I  want  to  grind  or  cut  into  the  sur- 
face, I  use  a  stiff  brush.  In  the  mouth  I  have  but  one 
idea,  and  that  is  to  clean  and  polish,  and  not  injure  any 
structure. 

I  demonstrated  in  m}'  office  to  several  dentists — ad- 
vocates of  the  hard  tooth  brush — by  cleaning  the  teeth 
of  a  patient  in  the  following  manner:  on  one  side,  I 
cleaned  with  a  camel's  hair  brush,  while  on  the  other  side 
I  used  a  medium  stiff  brush.  The  debris  was  cleaned  off, 
if  anything,  better  on  the  side  where  the  camel's  hair 
brush  was  used,  and,  on  the  side  where  the  stiff  brush 
was  used,  the  gums  were  in  a  bleeding  condition. 

Dr.  Arthur  Black  says,  ''I  have  seen  very  few  cases 
only  two  of  which  I  have  made  definite  record,  in  which 
the  gum  septa  have  been  inflamed  by  the  use  of  a  too 
stiff  tooth-brush.  In  both  cases,  there  was  marked  im- 
provement promptly  following  the  change  to  a  softer 
brush. ' ' 

Dr.  M.  L.  Fletcher  insists  that  his  patients  use  a  hard 
brush,  and,  in  addition,  that  the  teeth  be  scrubbed,  claim- 
ing that  in  addition  to  cleansing  the  teeth,  the  connective 
tissue  is  developed  to  a  high  degree  in  tliom.     This,  he 


100  Peactical  Oeal  Hygiene. 

says,  has  the  same  effect  on  the  teeth  and  gums  as  the 
mastication  of  hay,  twigs,  and  rough  food  has  on  the 
gTims  of  animals.  Dr.  Fletcher,  some  time  ago,  suggested 
that  corn  meal  was  as  good  a  cleanser  for  the  teeth  as 
was  needed,  claiming  that  it  has  sufficient  cleansing 
power  without  injury  to  the  gums.  He  also  objects  to 
dentifrices  that  contain  soap,  claiming  that  they  cause  the 
tooth  brush  to  slip  over  the  tarter  and  food  without  re- 
moving them.  On  the  contrary.  Dr.  N.  S.  Jenkins  claims 
that  this  is  the  most  important  thing  for  a  properly  pre- 
pared dentifrice. 

It  is  reasonable  to  believe  that  before  the  deposit  of 
tarter  takes  place,  there  must  be  some  cementing  sub- 
stance to  hold  it  in  place — some  agglutinizing  material; 
thus,  if  we  fail  to  brush  our  teeth  one  day,  this  material 
accumulates  on  the  teeth,  and  forms  the  beginning  of  cal- 
carious  deposits,  with  the  result  that  from  this  one  day's 
lack  of  brushing  a  rough  surface  is  left  for  the  beginning 
of  an  accumulation.  We  see  how  important  it  is  to  train 
our  patients  to  know  that  an  irregular  system  of  brush- 
ing the  teeth  fails,  and  that  for  brushing  the  teeth,  to  be 
successful,  it  must  be  regular  and  systematic,  with  no 
skips  in  between.  After  the  material  has  accumulated 
on  the  teeth  for  a  few  days,  it  is  impossible  for  the 
patient  to  remove  the  deposits,  and  he  must  report  to  the 
dentist. 

Dr.  Francis  says,  ''Some  mouths,  so  far  as  the  tooth 
brush  is  concerned,  are  unexplored  caverns  of  miniature 
type,  and,  others  which  receive  an  occasional  visit  from 
the  intrusive  explorer,  are  not  in  a  very  much  better  con- 
dition for  the  little  care  bestowed  upon  them." 

Expressions  as  the  one  just  cited  should  urge  us  to 
the  utmost  to  bring  about  a  change  of  thought  in  the 
minds  of  our  patients  toward  the  cleanliness  of  their 
mouths.  This  training  of  patients  to  brush  their  teeth 
properly  is  one  of  the  hardest  and  most  thankless  things 
that  the  dentist  has  to  do. 


Brushing  the  Teeth.  101 

the  dieection"  card. 

In  former  years,  before  I  used  the  printed  ' '  direction 
cards,"  mucli  time  was  spent  in  training  the  patients. 
When  at  a  subsequent  sitting,  if  asked  to  demonstrate 
how  they  were  brushing  their  teeth,  they  would  do  almost 
the  opposite  from  what  had  been  told  them.  The  patients 
way  you  told  me." 
often  replied  with  the  expression,  "Now  that  is  just  the 

DiRECTIOXS  FOR  THE  PROPER  CARE  OF  THE  TEETH. 

Upon  Rising  the  teeth  and  gums  should  be  most  carefully, 
thoroughly,  and  Correctly  Brushed — using  a  soft  grade  tooth 
brush  and  • . 

After  Breakfast,  Avased  floss  silk  should  be  passed  between  the 
teeth  (be  careful  not  to  snap  it  down  hard  upon  the  gtims,  as 
•this  would  injure  them)  or  a  quill  tooth  pick  should  be  used — 
never  use  a  Avood  tooth  pick. 

After  Dinner  or  luncheon,  when  possible,  waxed  floss  silk  or  a 
quill  tooth  pick  should  be  used  and  the  mouth  most  thoroughly 

washed  with ,  if  convenient^ — otherwise 

with  plain  water. 

After  Supper  repeat  the  above. 

Just   before  Retiring,  the  teeth   should  be   again   thoroughly 

and  Correctly  brushed  with  ' and  the 

mouth  thoroughly  rinsed  with  ' — . 

Don't  brush  across — brush  the  under  teeth  up  and  the  upper 
teeth  down — brush  hard — you  cannot  injure  the  teeth  or  ^ims; 
the  gums  will  soon  become  hard,  firm  and  healthy. 

For  foul  breath  nothing  equals  the  pleasant  odor,  taste,  and 

antiseptic  qualities  of « ' .  which  should 

be  used  in  good,  big  mouthfuls  and  retained  as  long  as  possible. 
Keep  the  teeth  shut  and  alternately  distend  and  draw  in  the 
cheeks,  forcing  the  fluid  between  the  teeth. 

Nothing  short  of  the  above  constitutes  good  care  of  the  teeth. 

{Tack  this  card  above  tooth  brush  holder). 

Fig.  14.     The  Dentist's  Favorite  Dentifrice  and  Mouth  Wash  is 
TO  BE  Inserted  in  Blanks. 

Now,  after  training  the  patients,  a  card  containing 
condensed  directions  for  the  care  of  their  teeth  is  given. 
They  are  requested  to  preserve  this  card.    The  patients 


102  Peactical  Oral  Hygieiste. 

will  get  a  better  idea  from  seeing  the  suggestion  in  print. 
Tlien  when  tliey  claim,  "just  as  you  showed  me,"  you 
have  all  the  advantage  by  using  another  direction  card. 
Dr.  Kells  was  the  first  to  suggest  to  me  the  advantages 
of  this  method.  All  dentists  should  have  printed  some 
card  giving  their  directions.  It  saves  time,  does  good, 
and  costs  little. 

On  the  direction  card  illustrated,  note  carefully  the 
word  "Correctly,"  and  the  technique  which  is  given; 
if  this  is  carried  out  it  will  remove  the  debris  from  the 
teeth,  and  give  a  better  massage  effect  to  the  gums  than 
any  other  method  with  which  I  have  experimented.  This 
results  in  the  bristles  going  into  the  interstitial  spaces. 

The  manner  in  which  most  people  brush  their  teeth 
resembles  the  way  in  which  the  small  boy  shines  his  shoes 
on  Sunday  morning.  He  shines  the  tips  all  right,  but, 
if  left  to  himself,  he  never  touches  the  heels.  People 
will  brush  their  front  teeth,  but  they  never  get  to  tha 
back  ones. 

In  brushing  the  teeth,  we  should  begin  at  some  defi- 
nite point,  such  as,  for  example,  the  upper  right  buccal 
surfaces.  The  brush  is  placed  with  the  bristles  pointing 
straight  up,  the  side  of  the  brush  against  the  gums.  A 
rotary  tilting  motion  revolves  the  bristles,  using  the 
hands  as  an  axis,  and  thus  forcing  the  bristles  between 
the  teeth.  The  brush  is  next  moved  around  to  the  front, 
and  then  the  left  buccal  surfaces.  Then,  in  order,  lirusli 
the  palatal  and  lingual  sides  of  the  teeth  with  the  same 
position  of  the  brush,  high  upon  the  arch,  and  turned 
outwards,  bringing  the  bristles  down  between  the  teeth. 
Then  the  occlusal  surface  of  the  molar  teeth  is  given  care- 
ful attention.  For  more  detailed  direction  for  brushing 
the  teeth  see  Dr.  Corley's  outline  lecture. 

Dr.  Pones  states  that  the  tooth  brush  be  made  to 
travel  as  fast  as  the  hand  can  be  made  to  go,  and  he  gives 
another  useful  point  in  brushing  the  inner  surfaces  of 
tlie  lower  teeth,  which  is,  to  have  the  patient  hold  the 
thumb  on  the  top  of  the  handle  instead  of  around  it. 


Beushixg  the  Teeth. 


103 


CLEANING  THE 

N5IDE:  or 

TNE  10\NLK 
mm  TEETh 


Fig.  15.     Showing  Important   Tooth  Brush   Movements. 


104  Peacticai.  Oral  HYGiEisrE. 

Tlie  brush  is  now  placed  in  the  right  side  in  just  the 
reverse  manner.  On  the  lower  jaw,  it  is  just  the  reverse 
as  on  the  upper.  Here,  the  bristles  point  straight  down, 
and  the  long-  side  of  the  brush  is  against  the  gums.  We 
now  bring  j)ressure,  and  rotate  the  brush  upwards.  The 
same  technique  is  brought  out  around  the  circle  of  the 
teeth,  but  when  we  come  to  the  lingual  sides  of  the  lower 
jaw  teeth,  we  have  to  change  our  technique.  Here,  the 
brush  has  to  be  pressed  between  the  tongue  and  the  molar 
teeth.  The  molars  should  be  brushed  with  an  in  and  out 
movement,  as  the  rotary  movement  would  be  of  no  use  on 
account  of  not  being  able  to  get  the  brush  below  the  gum 
margin.  The  lingual  surfaces  of  the  lower  incisors  is 
brushed  by  inserting  the  brush  as  far  down  as  possible, 
and  bringing  it  out  with  an  upward  movement.  We  must 
caution  the  patient  against  brushing  across  the  cuspids 
for  fear  they  will  cut  grooves. 

We  mean  when  we  say,  ''A  clean  tooth  will  not 
decay,"  that  the  pabulum  on  which  germ  life  will  feed 
has  been  removed,  or  rendered  inert. 

Dr.  A.  E.  Peck  gives  the  following  suggestions  for 
the  patient  to  use : 

"Impress  them  with  the  importance  of  removing  all 
deposits  of  food  or  other  material  which  would  form  a 
good  culture  ground  for  dangerous  germs.  These  de- 
posits under  the  margin  of  the  gums  can  be  removed  by 
the  patient  with  a  properly  shaped  stick  and  an  abrasive. 

"The  Tongue  Scraper,  Massage  Stick,  and  Polish 
will  assist  materially  in  this  work.  With  this  stick 
they  can  keep  the  tobacco  stains  from  their  teeth, 
and  prevent  many  plaques  from  forming.  The  mother 
can  use  this  stick  on  the  teeth  of  the  children  who  are 
too  young  to  come  to  the  dentist.  She  can  help  keep  their 
mouths  clean  and  healthy,  and  at  the  same  time  educate 
them  to  the  importance  of  having  their  teeth  attended 
to.  It  will  familiarize  them  with  having  others  work 
on  their  teeth,  and  when  they  do  come  to  the  dentist  they 


The  Bad  Breath  Signal. 


105 


will  be  mncli  more  easily  liandled,  and  better  results  will 
be  obtained. 


Fig.  1G.     The  Care  of  the  Tokgue  is  Oetek  Xeglected.     SoiiE 

SniPLE  Appliaxce  as  Above,  Properly  IJsed^  is  a  Great 

Aid  Towards  a  Cleax  JMouth. 

"The  value  of  the  tongue  scraper  was  recognized  by 
the  Chinese  many  years  ago,  and  a  jeweled  tongue  spoon 
was  a  part  of  their  toilet  requisites.  The  removal  of  the 
([isintegrated  mucus  from  between  the  papillae  of  the 
tongue  eliminates  from  the  body  a  fine  culture  ground 
for  all  kinds  of  bacteria.  The  tongue  scraper  should  be 
used  soon  after  rising  each  morning." 

TI-IE  bad  breath  SIGXAL. 

How  often  on  the  street  corner,  on  the  car,  in  the 
church  pew,  at  the  social  function,  and  in  the  dental  chair 
have  we  been  annoyed  by  having  to  associate  with  those 
individuals  who  suffer  from  bad  breath.  As  the  posses- 
sor of  the  bad  breath  is  not  aware  of  its  odor,  he,  conse- 


106  Peactical  Oral  HYGiEisrE. 

queutly,  does  not  know  tliat  he  is  so  afflicted,  and  it  does 
seem  that  he  always  wants  to  get  iip  close  to  yonr  face 
to  talk.  Strange  to  say,  some  of  these  very  people  carry 
out  to  the  best  of  their  ability  and  knowledge  the  ordinary 
rules  of  mouth  hygiene,  and  yet  this  condition  continues 
to  exist. 

This  is  a  very  delicate  matter  to  mention,  and  yet, 
there  is  no  one  so  well  placed  as  the  dentist  to  help  in 
this  respect.  The  subject  of  foul  breath  should  not  be 
discussed  with  these  patients,  for  they  are  very  sensitive 
on  the  subject.  However,  in  a  tactful  manner  of  speech, 
we  can  train  them  into  a  more  accurate  system  of  flossing 
the  teeth,  and  can  suggest  their  taking  up  a  system  of 
Prophylaxis.  If  we  do  this,  we  can  work  out  to  our  satis- 
faction the  cure  of  this  defect. 

Dr.  Geo.  M.  Niles,  a  Gastro-Intestinal  specialist,  has 
written  a  valuable  paper  on  the  subject  of,  ''The  Bad 
Breath:  What  it  Portends."  Some  extracts  from  this 
paper  give  us  valuable  information  on  this  subject. 

"When  the  personal  odor  is  offensive,  it  is  a  great  misfortune;  if 
preventable,  it  is  an  inexcusable  disgrace. 

"In  the  ordinary  intercourse  between  individuals,  the  exhaled  breath 
generally  constitutes  the  most  noticeable  odor,  and  it  is  to  that  phase 
of  the  subject  this  study  is  mainly  directed. 

"Every  one  of  my  readers  can  probably  call  to  mind  one  or  more 
acquaintances,  who,  except  for  an  abominable  breath,  would  be  attrac- 
tive; but  from  the  presence  of  this  handicap,  are  avoided,  perhaps  dis- 
Uked. 

"A  busy  dental  surgeon,  of  this  city,  who  has  offices  in  the  same 
building  with  a  rectal  specialist,  recently  informed  me  that,  on  com- 
paring notes,  they  both  decided  that  the  dentist,  in  his  daily  routine, 
encountered  more  offensive  and  septic  cavities  than  did  the  latter  in 
his  rectal  work. 

"The  mouth,  as  the  portal  of  entrj'  for  food  and  air,  warm  and 
moist,  with  numerous  nooks  and  crannies,  where  stray  particles  of  food 
and  other  debiis  may  furnish  an  inviting  field  for  countless  miero-oi-gan- 
isms,  is  by  far  the  most  fruitful  source  of  bad  breath.  Among  other 
causes  in  and  adjoining  the  mouth,  besides  carious  teeth,  pyon'hea 
alveolaris,  tartar,  septic  gums,  glossitis  or  stomatitis,  may  be  men- 
tionod  necrosis  of  the  nasal  bones,  iiurulont  hypertrophic  or  atrophic 


Lime  Water  as  a  Mouth  Wash.  107 

rhinitis,  ozena,  septic  tousilitis,  or  even  squamous-eelled  carcinoma  of 
the  mouth  or  tongaie. 

"After  all  is  said,  however,  it  must  be  admitted  that  we  occasionally 
see  a  patient  in  whom  no  adequate  cause  can  be  found,  but  who,  never- 
theless, labors  under  this  misfortune.  Though  it  is  possible  that  such 
may  be  due  to  some  lamentable  jDcrsonal  idiosyncrasy,  we  should  be 
slow  to  admit  such  a  contingency.  In  these  rare  cases  a  jDersistent 
search  ■^dll  sometimes  disclose  a  putrefying  impaction  in  some  almost 
inaccessible  recess  in  the  mouth,  where  neither  toothbrush  nor  denti- 
frice can  penetrate.  A  dentist  of  experience  of  this  city,  stated  to  me 
that  a  breath  of  surprising  foulness  could  be  produced  by  one  small 
impaction  of  this  sort — so  small  as  to  be  discovered  only  after  patient 
search. 

"Successful  management  by  the  physician  or  dental  surgeon  will 
afford  such  relief  from  embarrassment  to  the  patient  and  annoyance 
to  friends,  that  well  may  the  emancii^ated  sufferers  'rise  up  and  call 
him  blessed.' " 

While  most  cases  of  foul  breath  are  clue  to  mouth  con- 
ditions of  the  patient,  it  may  come  in  some  degree  from 
constipation  or  intestinal  intoxication.  Generally,  in  un- 
complicated cases,  the  taking  of  some  purgative  medicine, 
as  one  teaspoonfull  of  epsom  salts,  before  breakfast,  for 
a  week  or  ten  days  together  with  larger  quantity  of 
water,  will  help  this  condition. 

LIME   WATEE   AS   A   MOUTH    WASH. 

The  number,  kinds,  and  styles  of  dentifrice  and  mouth 
wash  formulae  are  legion.  It  is  not  the  intention  of  the 
writer  to  enter  into  a  discussion  of  their  relative  merits, 
except  to  say  that  it  is  not  so  much  which  brand  is  used 
as  the  ivay  in  which  it  is  used. 

As  many  of  our  prominent  dentists  have  become  such 
'strong  advocates  to  the  use  of  lime  water  for  a  mouth 
wash,  the  method  of  its  preparation  will  be  given. 

Dr.  Kells,  of  New  Orleans,  was  one  of  the  first  advo- 
cates of  lime  water  as  a  mouth  wash.  As  the  proper 
quality  of  lime  is  rather  hard  for  the  patients  to  secure, 
he  keeps  this  put  up  in  two-ounce  bottles  for  supplying 
his  patients.    His  idea  is  that  if  the  patient  uses  a  pro- 


108  Peactical  Oral  Hygiene. 

prietary  moutli  wasli  in  as  large  quantities  as  he  pre- 
scribes, it  wonld  be  too  expensive  for  tliem. 

Noticing  that  Dr.  Fones,  of  Bridgeport,  Connecticut, 
also  recommends  lime  water,  I  asked  Mm  to  give  his 
opinion  relative  to  the  recent  publication  of  Pickerill, 
who  claims  that  all  alkaline  mouth  washes  prevent  a  free 
flow  of  saliva,  and,  as  the  saliva  is  the  best  mouth  wash 
possible,  the  use  of  lime  water  does  not  have  the  desired 
effect.  My  personal  experience  was  that  it  always  left 
a  furred  feeling  instead  of  a  cleanly  one. 

In  answer  to  these  queries,  Dr.  Fones  wrote  me,  and 
I  quote  at  length: 

' '  The  reason  why  I  am  such  an  advocate  of  lime  water 
for  a  mouth  wash  is  that  it  is  such  a  powerful,  3'et  harm- 
less, solvent  for  the  mucilagenous  accumulations  around 
the  necks  of  the  teeth,  as  well  as  their  proximal  surfaces. 

''Kirk  has  found  by  scientific  experiments  that  it  is 
one  of  the  best  solvents  for  placques  and  gummy  accre- 
tions of  the  teeth  that  has  come  under  his  observation. 
Its  alkiline  reaction  does  not  especially  enter  into  the 
subject  in  consideration  of  its  merit.  If  you  will  secure 
the  coarse  lime,  which  is  a  very  light  cream  color,  and 
prepare  it  in  the  following  manner,  I  am  sure  you  will 
not  have  any  furry  effect  in  your  mouth,  but  one  of  ex- 
treme cleanliness. 

"Place  a  half  cup  of  the  unslacked  lime  in  an  empt}?- 
quart  bottle,  and  then  fill  with  cold  water.  Thoroughly 
shake  and  allow  the  lime  to  settle.  Pour  down  the  sink 
all  the  water  you  can  without  losing  any  of  the  lime,  as 
this  first  mixture  contains  the  washings  of  the  lime. 
Again  fill  with  cold  water  and  shake,  and  when  this  has 
settled  pour  off  some  of  the  clear  water  in  a  ten  or  twelve 
ounce  bottle  for  use  at  the  bowl  and  again  fill  the  quart 
bottle  with  cold  water,  shake  and  set  aside  for  future 
use.  This  operation  may  be  repeated  until  five  or  six 
quarts  of  the  mouth  wash  has  been  used.  If  the  lime 
water  is  a  trifle  strong  at  the  start,  dilute  that  in  the 


JjIme  Watek  as  a  Moitth  "Wash.  109 

small  bottle  with  water.  After  rinsing  the  mouth  with 
the  lime  water  (and  the  rinsing  should  be  of  sufficient 
length  of  time  to  thoroughly  foam  it),  rinse  the  mouth 
with  clear  warm  water.  I  have  yet  to  find  anything  to 
beat  it." 


CHAPTER     IX. 
CLEANINd  THE  TEETH. 

SKILL  REQUIEED  FOR  THE   WORK. THE   BEST   TIME   TO    CLEAX 

THE    patient's    TEETH.  —  THE    USE     OF    A    DISCLOSING 

SOLUTION. INSTRUMENTS     USED     FOR     CLEANING 

THE  TEETH. ABRASIVE  MIXTURES  TO  BE  USED 

IN   CLEANING  THE  TEETH. 

Under  the  term,  ''Cleaning  the  Teeth,"  will  be  de- 
scribed the  operative  measures  employed  at  the  dental 
chair  for  removing*  deposits,  bacterial  placques,  and 
stains  from  the  average  mouth.  This  term  does  not  give 
sufficient  dignity  to  the  work,  and  all  investigators  who 
work  along  this  line  will  be  glad  for  a  better  term.  None 
has  been  forthcoming,  and,  as  all  our  patients  know  what 
we  mean  when  we  use  this  term,  it  is  one  which  we  will 
more  often  be  forced  to  use  with  them.  If  our  clientele 
understand  ''Removing  Infection,"  or  "Prophylaxis 
Treatment,"  then  these  terms  can  better  be  employed. 

It  seems  rather  a  strange  coincidence  that  a  few  years 
ago,  the  dentist  who  "cleaned  teeth,"  was  in  danger  of 
losing  his  club  and  social  standing,  but  within  the  last 
few  years,  the  importance  of  this  procedure  has  so  im- 
pressed itself  upon  the  patients  that  the  man  who  does 
not  clean  the  teeth  of  his  patients,  or  have  it  done,  is 
looked  upon  as  one  either  behind  the  times  or  failing  in 
his  legitimate  duty  to  his  patients.  There  was  a  time 
when  our  profession  would  put  in  beautiful  fillings,  and 
send  the  patients  away  with  a  clean  bill  of  health,  al- 
though the  free  margin  of  the  gums  exhibited  rings  of 
calcarious  deposits.  It  was  not  many  years  ago  that  the 
patient  would  not  pay,  or  rather  was  not  required  to 
pay,  more  than  from  one  to  three  dollars  for  this  opera- 
tive procedure.  Many  of  the  laity  were  accustomed  to 
having,  as  the  Indians  express  it,  the  cleaning  put  in  as 


Cleaxixg  the  Teeth.  Ill 

*'potlash,"  that  is,  where  any  work  was  done,  the  clean- 
ing was  added  free  of  charge.  In  view  of  this  state  of 
affairs,  it  is  not  to  be  wondered  at  that  there  was  so  little 
cleaning  of  the  teeth  done  by  the  dentists.  It  was  also 
a  deplorable  fact  that  onr  colleges  paid  little  heed  to  this 
subject,  and  many  gi'aduates,  during  their  college  days, . 
never  saw  a  mouth  properly  cleaned  up  by  their  profes- 
sor or  demonstrator.  If  the  college  did  any  of  this  work, 
it  was  relegated  to  the  freshmen. 

SKILL   EEQUIEED   FOR   THIS   WOEK. 

From  the  belief  that  any  one  can  clean  k  set  of  teeth, 
we  are  now  learning  that  this  operation  requires  most 
expert  ability,  and  thorough  knowledge  of  anatomical 
landmarks,  as  well  as  medical  treatment  for  pathological 
conditions.  Generally,  the  placing  of  fillings  is  mere 
routine  work,  but  the. more  teetb  we  clean,  and  the  more 
mouths  we  j)ut  in  a  healthy  condition,  the  more  we  realize 
that  greater  skill  is  required  here  than  in  any  other  line 
of  work  which  we  do.  We  have  learned  that  the  average 
patient  cannot  maintain  clean  teeth,  and  that  they  will 
have  to  have  our  professional  assistance  along  this  line. 
We  have  also  learned  that  this  work  is  of  immense  value 
to  the  patients,  and  that  it  is  worthy  of  a  reasonable  com- 
pensation which  will  enable  us  to  pay  more  attention  to 
the  matter. 

To  secure  a  clean  set  of  teeth — -one  that  would  be  so 
considered  by  a  specialist  in  prophylaxis — is  one  of  the 
most  difficult  procedures  in  dentistry.  It  behooves  us  to 
put  just  as  much  time  on  this  work  as  practicable,  or,  in 
the  event  the  patient  is  one  who  will  appreciate  this  ser- 
vice, as  much  time  should  be  given  him  as  would  accom- 
plish the  proper  cleansing  of  the  teeth. 

THE  BEST  TIME  TO   CLEAN   THE  PATIENT 's  TEETH. 

A  surgeon  would  not  dare  perform  any  operation 
without  first  making  some  attempt  at  cleaning  and  steri- 


112  Peacticai.  Oral  Hygiene. 

lizing  the  field  of  operation,  but  the  dental  surgeons  ab- 
solutely ignore  these  rules  of  surgical  procedure.  I  do 
not  think  that  any  dental  operation  should  be  undertaken 
until  the  teeth  have  first  been  properly  cleaned.  This 
should  be  done  as  routine  work.  There  are  many  ad- 
vantages resultant  from  this  procedure.  In  the  first 
place,  it  puts  the  cleaning  operation  on  a  higher  plane 
than  if  it  were  done  when  the  regular  dental  work  is 
finished.  In  the  second  place,  it  enables  us  to  bring  for- 
ward the  salient  points  of  oral  hygiene  to  the  patients. 
In  the  third  place,  it  protects  the  dentist  from  any  in- 
fection, should  any  of  these  germs  be  absorbed  through 
a  break  of  the  skin  in  his  hands.  In  the  fourth  place, 
it  prevents  hini  from  having  the  possible  infection  of  hay 
fever,  la  grippe,  and  tuberculosis,  for,  if  the  mouth  be 
properly  cleaned  out,  the  danger  of  infection  from  this 
source  will  be  reduced  to  a  minimum.  In  the  fifth  place, 
there  is  no  doubt  in  my  mind  that  if  the  mouth  is  prop- 
erly cleaned  out  before  the  work  is  done,  crowns  and 
bridges  will  stay  and  last  longer.  There  are  many  other 
reasons  that  I  could  enumerate,  but  these  are  enough  to 
impress  the  matter  on  the  mind  of  the  dentist.  Again,  I 
w^ould  like  to  repeat,  '^' Clean  or  have  cleaned  every  set 
of  teeth  before  you  operate." 

Eight  here  comes  the  question,  ''Who  shall  do  this 
ivork?"  Some  of  us  have  dental  nurses  in  our  offices, 
and  to  them  is  intrusted  this  work.  I  have  seen  better 
work  done  along  this  line  by  them  than  by  many  dentists. 
If  you  can  train  up  an  assistant  to  do  this  work,  well  and 
good. 

The  methods  employed  in  cleaning  the  teeth  are  many 
and  varied.  Whatever  method  is  employed,  let  us  be 
sure  that  the  patient's  gums  and  lips  are  not  torn  up  with 
the  instruments  or  the  floss  silk.  All  of  us  have  seen 
patients  with  their  mouths  so  sore  that  they  could  not 
brush  their  teeth  for  a  day  or  two,  or  even  chew  their 
food  properly,  following  the  simple  operation  of  cleaning 


Cleaning  the  Teeth,  113 

the  teetli.    There  is  no  need  for  any  great  physical  force 
to  be  exerted  in  the  operation. 

THE   USE    OF    A   DISCLOSING    SOLUTION. 

In  beginning,  it  is  well  to  spray  the  mouth  with  a 
solution  containing  aromatic  spirits  of  ammonia,  diluted 
three  times  with  water.  This  removes  the  viscosity  of 
the  saliva,  and  removes  all  decomposed  particles  of  food. 
It  is  a  strong  cleanser,  and  has  a  pleasant  effect.  We 
now  paint  the  teeth  with  some  staining  solution,  the  best 
of  which  is  Skinners'  Disclosing  Solution. 

FORMULA    FOR    1    OZ.    DISCLOSING    SOLUTION. 

Iodine   (ei-ystals)    grs.  50 

Potassium  Iodide grs.  15 

Zinc  Iodide   grs.  15 

Glj^cerin     drs.     4 

Aqna     drs.     4 

Mix.  Sig.  paint  teeth  (one  or 
'two  at  a  time)  and  rinse  immediate- 
ly with  water. 

Put  Tip  in  dass  stojipev  hottle. 

In  making  it,  put  the  iodine,  zinc,  and  potassium 
iodide  into  a,  mortar  with  five  or  ten  drops  of  glycerin. 
Grind  to  a  thick  syrup,  and  then  pour  all  you  can  into 
the  bottle.  Pour  the  remaining  glycerin  into  the  mortar, 
and  stir  with  a  pestle.  Pour  out  again,  then  add  water, 
and  stir  again.  In  this  way  you  can  get  all  the  solids  out 
of  the  mortar,  whereas,  if  the  solids  and  liquids  were  all 
put  in  at  once,  some  of  the  iodine  would  stick  to  the 
morter,  and  an  inferior  staining  solution  would  be  the 
result.  This  solution  shows  up  the  bacterial  placques, 
and  aids  in  removing  them. 

INSTKUMENTS  USED  FOR  CLEANING   TEETH. 

There  are  many  and  varied  instruments  in  the  market 
for  removing  calculus,  and  with  most  of  them  you  can 
obtain  good  results.     It  is  a  question  of  personal  equa- 


114  Peactical  Okal  Hygiene. 

tion.  I  would  caution  yoii  to  select,  and  use  the  smaller 
instruments.  Many  colleges  have  on  their  required  in- 
strument list,  scalers  which  suggest  plows,  rather  than 
dental  instruments.  The  writer  has  for  years  been  an 
advocate  of  the  Good- Younger  instruments  for  this  work, 
for  the  reason  that  they  can  be  used  either  "push"  or 
"pull,"  and,  being  small  and  roimded  on  the  back,  do  not 
injure  the  tissue;  they  are  rights  and  lefts  and  can  be 
used  in  a  double  ended  handle,  simplifying  operating  a 
great  deal. 

The  students  should  be  taught  that  pyorrhea  work  is 
on  the  same  principal  as  cleaning  the  teeth,  and,  if  they 
hope  to  operate  for  pyorrhea,  they  must  become  adept 
in  cleaning  teeth.  With  this  thought  in  view,  let  me  urge 
that  much  care  be  taken  in  the  use  of  whatever  instru- 
ments are  selected  for  this  work. 

It  takes  a  separate  set  of  instruments  for  this  work, 
and  for  the  pyorrhea  work,  for  here  we  do  not  wish  the 
instruments  to  be  sharp.  It  is  advisable  to  round  off 
the  sharp  edges  of  the  set  intended  for  cleaning  the  teeth. 
Much  injury  can  be  done  to  the  peridental  membrane  if 
its  attachment  is  separated  at  the  gingival  border.  Use 
a  chip  blower,  or  a  strong  current  from  the  compressed 
air  syringe,  and  blow  at  the  gingival  margin,  thus  forcing 
the  margin  of  the  gums  away.  This  enables  the  operator 
to  see  the  small  patches  of  infection  or  deposit  which 
have  been  previously  stained  by  the  solution.  The  assis- 
tant can  so  manipulate  the  air  syringe  as  to  be  of  great 
aid  to  the  operating  dentist.  Now,  as  in  pyorrhea  work, 
to  be  skillful,  one  must  brace  his  fingers  on  the  teeth,  so 
that  no  slip  of  the  instrument  can  occur.  The  number 
15  is  used  for  removing  deposits  on  the  anterior  teeth, 
while  the  numbers  3  and  4,  right  and  left,  are  used 
for  removing  material  from  the  posterior  teeth.  The 
small  blade  of  the  instrument  should  be  run  completely 
around  the  free  margin  of  the  gums,  for  we  have  found 
this  to  be  the  starting  point  of  many  pathological  con- 
ditions of  the  gums.    It  does  no  more  harm  to  carefully 


Cle AIDING  THE  Teeth.  115 

clean  out  this  free  margin  than  it  does  to  clean  out  the 
finger  nails.  In  fact,  one  of  the  tests  that  I  make  of  new 
instruments  is  to  run  them  under  my  thumb  nail,  and, 
if  it  cleans  the  cuticle  there  without  injury,  it  will  do  to 
use  on  the  free  margin  of  the  g-um. 

After  the  instrumentation  has  been  done,  the  next 
procedure  is  the  use  of  waxed  dental  floss  silk  between 
the  teeth.  The  usual  round  dental  floss  will  not  give  the 
desired  results.  You  must  have  a  flat  floss  to  do  the  work 
properly.  It  must  also  be  as  large  as  can'  be  forced  be- 
tween the  teeth.  On  this  floss  we  use  an  abrasive  con- 
sistent with  the  amount  of  infection  which  is  to  be  re- 
moved. If  the  spaces  between  the  teeth  are  large,  and 
considerable  debris  is  to  be  removed,  then  we  may  use 
an  abrasive  containing  flour  of  pumice.  On  the  other 
hand,  if  the  patient's  mouth  is  in  fairly  good  condition, 
we  need  not  use  such  an  abrasive  powder,  but  use  a  chalk 
mixture  or  one  of  the  formulas  which  I  am  giving  at  the 
end  of  this  chapter.  There  is  one  caution  to  be  borne 
in  mind,  and  that  is,  in  using  large  size  silk,  place  the 
thread  between  the  teeth,  and  then  place  on  whatever 
abrasive  is  to  be  used.  If  we  placed  the  abrasive  between 
the  teeth,  and  then  attempt  to  pass  the  silk,  we  would  find 
it  almost  impossible  to  do  so,  and,  even  if  it  did  go,  one 
half  of  the  floss  silk  would  be  cut  in  two. 

It  is  not  necessary  to  saw  the  gaims  or  the  cheek  with 
the  silk,  nor  is  it  necessary  to  fill  the  mouth  with  the 
abrasive  material.  The  smallest  amount  is  all  that  is 
necessary.  The  silk  should  be  passed  thoroughly  be- 
tween all  the  teeth  and  threaded  under  whatever  bridges 
the  patient  may  wear.  "When  this  is  done,  the  patient's 
mouth  must  be  thoroughly  rinsed  out  with  a  syringe,  or 
sprayed  with  compressed  air,  and  then  some  mild  anti- 
septic mouth  wash  used. 

We  are  now  ready  to  cleanse  the  bodies  or  the  crowns 
of  the  teeth.  If  you  have  the  skill,  and  the  time,  there 
is  no  better  method  than  the  orange  wood  stick  and  dry 
pumice  flour,  but,  while  this  is  the  ideal  method  in  pro- 


116  Practical  Oral,  Hygiene. 

pliylaxis,  for  the  simple  cleansing  of  the  teeth,  most  of 
ns  will  use  the  dental  engine.  There  are  many  and  varied 
devices  at  our  command  for  use  on  the  engine  in  our  hand 
piece.  Possibly,  you  have  adopted  the  bristle  brush  as 
being  the  most  efficient;  nothing  has  yet  been  found  equal 
to  the  brush  wheel  for  polishing.  We  should  have  one 
right  angle  hand  piece  set  aside  for  this  \vork.  Surely, 
everybody  has  an  old  right  angle  that  can  be  dedicated  to 
this  work.  I  have  never  been  able  to  do  this  class  of 
work  with  a  straight  angle  hand  piece,  and  any  one  who 
has  used  a  right  angle  for  cleaning  teeth  with  a  bristle 
brush,  will  never  use  a  straight  one  again.  Formerly,  I 
had  a  great  deal  of  trouble  with  my  right  angle  in  this 


Fig.  Vi 


work,  because  of  the  abrasive  getting  into  it,  but  now  T 
use  the  Consolidated  Dental  Mfg.  Co 's.,  right  angle,  which 
completely  closes  at  the  back,  and  by  inserting  a  rubber 
cup  on  backwards,  I  can  keep  the  abrasive  out  of  the 
mechanism.  Needless  to  say,  a  fresh  brush  is  furnished 
to  every  patient.  However,  I  can  see  no  objection  to 
these  brushes  being  saved,  and,  at  the  end  of  the  week, 
being  cleansed  by  boiling  for  fifteen  or  twenty  minutes, 
and  used  in  future  operations. 

These  inverted  bristles  can  be  had  in  a  stitT  grade, 
which  are  black,  and  in  a  soft  grade,  which  are  white, 
also  in  camel's  hair  brushes.  The  unmounted  kind  are 
the  ones  used  in  right  angle  hand  piece,  using  the  short- 
est right  angle  mandrel. 

With  the  sharpened  orange  wood  stick,  place  around 


Cleaning  the  Teeth.  117 

the  teetli  the  abrasive,  and  with  the  dental  engine  run  at 
a  low  rate  of  speed,  carefully  go  over  all  surfaces  of  the 
teeth,  giving  the  hand  piece  a  motion  from  the  gum 
toward  the  cutting  or  grinding  surface  of  the  teeth.  The 
mouth  is  again  washed  out,  and  the  staining  solution  ap- 
plied as  at  first.  If  there  is  any  debris,  bacterial  plaques, 
or  calculus  still  remaining,  this  staining  solution  will  im- 
mediately show  them  up. 

Now  comes  one  of  the  most  important  parts  of  the 
operation— the  careful  removal  from  under  the  free 
margin  of  the  gums  all  trace  of  the  abrasive  that  has  been 
used.  It  takes  force  to  remove  this  material,  and  calls 
for  the  highest  pressure  which  we  can  put  on  the  air  or 
water  syringe.  We  must  bear  in  mind  that  this  abrasive 
has  sharp  edges,  and,  if  left  under  the  gum  margin,  ijiaj 
cause  irritation  or  pyorrhea!  conditions.  The  mouth 
should  then  be  rinsed  out  with  cold  water,  and,  as  a 
finishing  touch,  I  advise  that  some  lotion  as  Holmes' 
Fragrant  Frostilla  be  applied  to  the  lips,  which  have 
necessarily  had  much  unpleasant  stretching.  "When  this 
technique  is  carried  out,  and  the  proper  dental  toilet  ex- 
plained, the  patient  is  delighted  and  is  usually  willing- 
to  pay  liberally  for  the  services  rendered. 

abeasive  mixtuees  to  Be  used  in  cleaning  the  teeth. 

Ordinary  powdered  pumice  can  be  mixed  with  either 
tincture  iodine,  alcohol,  or  peroxide  of  hydrogen.  The 
iodine  stains,  the  alcohol  is  the  best  antiseptic,  while  the 
peroxide  is  good  to  remove  green  stains. 

To  a  teaspoonfull  of  pumice  can  be  added  about  ten 
drops  aromatic  sulphuric  acid.  This  is  splendid  for 
tobacco  stains. 

The  above  should  only  be  used  where  the  teeth  are  in 
a  bad  condition. 

Flour  of  pumice  is  much  finer,  and  should  be  substi- 
tuted for  the  regular  pumice,  if  possible.  It  can  be  mixed 
with  anv  of  the  above  drugs. 


118  Peactical  Oral  Hygiene. 

If  the  teeth,  are  in  a  fair  condition,  it  is  best  to  make 
a  teaspoonfull  of  any  good  dentifrice  or  tooth  paste,  and 
incorporate  with  it  a  small  quantity  of  flour  of  pumice. 

Any  of  the  above  can  be  used  either  with  dental  en- 
gine or  hand  cleaning  with  porte  polisher. 


PART  II. 

PRACTICAL  ORAL  PROPHYLAXIS 


CHAPTEE     X. 
ORAL  PROPHYLAXIS. 

DEFINITIOlSr    AiSTD   VIEWS   OF    SMITH,   SPALDING,   FLETCHER, 
FONES,   TAYLOR,   RHEIJST   AND   HARPER. 

It  was  some  years  ago  at  a  meeting  of  the  National 
Dental  Association,  in  Washington,  that  I  first  heard  any 
thing  definite  on  oral  prophylaxis,  and  became  interested 
in  this  subject.  At  this  time  it  was  my  pleasure  to  listen 
to  a  paper  read  by  Dr.  D.  D.  Smith,  of  Philadelphia,  and, 
a  few  days  afterwards,  to  meet  him  personally  in  his 
office.  This  meeting  changed  my  entire  method  of  con- 
ducting practice,  and  led  me  into  the  channels  of  prophy- 
laxis. While  it  is  true  that  this  subject  of  oral  hygiene, 
prophylactic  treatment  and  j^rophylaxis  has  been 
brought  up  in  various  meetings,  there  is  no  doubt  that 
Dr.  Smith  was  the  first  dentist  to  advocate  a  systematic 
treatment  along  this  line.  His  first  paper  was  read  Octo- 
ber 18th,  1898.  According  to  his  own  statement,  this 
paper  excited  no  interest  among  the  dentists  themselves. 
Some  years  later,  by  inviting  dentists  to  visit  his  office, 
and  exhibiting  a  large  number  of  patients  to  whom  he 
had  been  giving  this  treatment,  he  convinced  many  of  the 
leaders  of  the  profession  that  this  was  really  a  new  de- 
parture. It  was  interesting  to  note,  that  while  many 
were  interested,  and  went  home  to  put  the  idea  into  prac- 
tice, many  criticised  him  severely.  In  Washington,  it 
was  said  that  they  did  not  need  any  one  from  Philadel- 
phia to  teach  them  to  clean  teeth.  Another  one,  sup- 
posed to  be  a  teacher  in  a  dental  college,  said  that  it  was 
a  great  craze.  Many  said  that  it  would  polish  away  the 
enamel.     Some  said  that  a  tooth  held  against  a  brush 


122  Practical  Oeal  Hygiene. 

wheel  was  in  time  worn  away,  and  that  this  would  be 
the  way  with  teeth  under  prophylactic  treatment. 

Dr.  Smith's  plan  of  frequent  treatment  was  based  on 
the  fact  that  tooth  decay  begins  at  a  vulnerable  point  on 
the  outside,  and  proceeds  inward  along  the  tubuli.  It 
mattered  not  to  him  whether  this  disease  was  caused  b}^ 
lactic  acid.  He  contended  that  the  decay  of  teeth  de- 
IDendecl  upon  our  care  exercised  over  environmental  con- 
ditions. To  him  the  place  of  decay  or  the  resting  place 
of  the  bacterial  plaques  was  to  be  forcibly  removed.  This 
being  done,  we  have  changed  the  tooth  conditions  from 
bad  to  good,  and  have  removed  the  means  by  which  decay 
and  disease  gain  a  foothold. 

In  answer  to  the  question,  "What  is  Prophylaxis 
Treatment?"  there  can  be  no  better  answer  than  that 
written  by  the  originator  of  this  systematic  treatment. 

"The  treatment  consists  of  enforced  radical  and 
systematic  change  of  environment  of  the  teeth  and  per- 
fect sanitation  for  all  organs  of  the  mouth.  Experience 
having  demonstrated  that  the  most  careful  and  painstak- 
ing are  unable,  with  the  agents  commonly  employed — as 
the  tooth  brush  and  dentifrice,  took  pick  and  dental  floss, 
soaps,  so-called  germicidal  washes  or  other  agencies — to 
effect  this  end,  the  plan  of  forcible,  frequently  renewed 
sanitation  by  an  experienced  operator  has'  been  found 
indispensable.  In  detail,  oral  prophylaxis  consists  of 
most  careful  and  complete  removal  of  all  concretions, 
calcic  deposits,  semisolids,  bacterial  placques  and  inspis- 
sated secretions  and  excretions  which  gather  on  the  sur- 
face of  the  teeth,  between  them,  or  at  the  gum  margins; 
this  operation  should  be  followed  by  thorough  polishing 
of  all  tooth  surfaces  by  hand  methods  (power  polishers 
should  never  be  used),  not  alone  the  more  exposed  labial 
and  buccal  surfaces,  but  the  lingual,  palatal  and  proximal 
surfaces  as  well,  using  for  this  purpose  orange  wood 
points  in  suitable  holders,  charged  with  finely-ground 
pumice  stone  as  a  polishing  material.     Treated  in  this 


Definition.  123 

manner  the  teetli  are  placed  in  tlie  most  favorable  con- 
dition to  prevent  and  repel  septic  accumulations  and 
deposits,  and  not  less  to  aid  all  efforts  of  the  patient  in 
the  direction  of  cleanliness  and  sanitation." 

To  my  idea  nothing  short  of  the  above  meets  the 
requirements  of  prophylaxis. 

Dr.  E,  B.  Spalding  in  a  paper  before  the  Michigan 
Dental  Society  said : 

''One,  two  or  three  treatments  does  not  constitute 
jDrophylaxis.  It  is  the  constant  watching,  guarding  and 
maintaining  the  mouth  in  a  condition  of  health  which  con- 
stitutes oral  prophylaxis." 

Another  definition  by  Dr.  M.  H.  Fletcher  is  as  fol- 
lows : 

''The  name  prophylaxis  means  preventive  as  you 
know,  and  is  the  work  that  should  be  done  by  the  patient 
in  cleansing  the  mouth.  When  a  surgeon  removes  a 
foreign  body  from  the  qjq  or  treats  a  wound  in  any  man- 
ner he  calls  it  by  its  proper  name,  viz.,  surgical  treatment. 
When  a  dentist  treats  the  disease  of  the  mouth,  he  is  not 
doing  preventive  work,  but  surgical  work,  just  as  any 
other  surgeon  does,  and  I  think  the  dental  profession 
should  rise  to  the  occasion,  and  prove  to  the  medical 
world  as  well  as  to  the  laity  that  they  are  scientific  men. 
This  can  only  be  done  b}^  using  the  proper  terms  to 
describe  the  locations  and  pathology.  This  will  indicate 
that  they  know  what  they  are  doing." 

Dr.  Fones  calls  prophylaxis',  "the  ideal  ser^dce  to  the 
patient." 

In  as  much  as  the  terms  oral  hygiene,  prophylactic 
treatment,  and  prophylaxis  have  caused  so  much  mis- 
understanding, it  is  not  to  be  wondered  at  that  this  work 
has  not  found  its  way  into  the  general  routine  of  more 
dental  offices.  Granting  that  all  we  have  said  about  oral 
hygiene,  even  if  this  is  practiced  to  the  fullest  extent,  it 
still  remains  that  we  must  imbibe  some  of  the  spirit  and 


124:  Peactical  Oral  Hygiene. 

intent  of  prophylaxis  to  carry  out  the  treatment  as  it 
should  be  carried  out.  It  is  a  lamentable  fact  that  so 
few  dentists  in  the  United  States  do  this  work  in  a 
systematic  way.  In  1911,  I  made  a  tour  of  most  of  the 
large  cities  of  the  United  States,  and,  after  hearing- 
numerous  papers,  seeing  exhibits  at  societies,  and  read- 
ing a  mass  of  magazine  articles  on  this  subject,  I  realized 
that  little  had  been  done  in  the  carrying  out  of  systematic 
work  along  this'  line,  and  few  had  imbibed  the  true  spirit 
of  preventive  dentistry.  On  June  21st,  1911,  I  read  a 
paper  before  the  Florida  State  Dental  Society  upon  the 
subject,  ''Introduction  of  Oral  Hygiene  into  a  Dental 
Practice."  In  this  paper  I  gave  some  interesting  corres- 
pondence contributing  to  the  historical  data  of  the  subject 
of  oral  prophylaxis.  This  paper  was  published  in  the 
Dental  Summary  in  December,  1911.  I  quote  at  length: 
''Several  years  ago  the  dental  profession  was  con- 
fronted by  the  fact  that  one  of  its  mem/bers,  a  competent 
dentist,  a  social  favorite,  a  refined  and  cultured  gentle- 
man, had  been  blacklisted  from  membership  in  a  swell 
■social  club  for  no  other  reason  that  that  he  "cleaned 
teeth."  Nor  was  this  stigma  on  prophylaxis  confined  to 
the  laity.  Dentists  seemed  to  think  it  beneath  their 
dignity  to  clean  teeth,  and,  if  it  must  be  done,  it  was 
relegated  to  the  assistant.  Others  tell  us  that  it  takes  a 
crank  to  work  prophylaxis.  Dr.  Levi  C.  Taylor,  of  Hart- 
ford, wrote  me  on  February  7th,  190-5,  'I  find  upon  inves- 
tigation that  it  (prophylactic)  means  a  medicine  or  medi- 
cal treatment,  the  word  being  very  old  in  this  connection. 
Dr.  M.  L.  Rhein  took  exception  to  this,  and  claimed  it  to 
be  a  word  taken  from  the  name  of  a  tooth  brush  in  1882. 
Prophylaxis  came  into  use  in  the  sixties,  and  was  defined 
by  Donaldson,  in  1874,  very  much  as  I  defined  it  at  your 
meeting,  'Surgical  or  manipulative  treatment  for  the 
preservation  of  teeth.  That  both  are  a  treatment  no  one 
will  deny,  but  I  do  believe  that  each  has  a  distinct  mean- 
ing. Men  and  women  both  belong  to  the  human  family. 


Definition.  125 

but  wlio  would  think  of  using  the  words  interchangably 
as  meaning  one  and  the  same  thing?' 

'^Dr.  M.  L.  Ehein  wrote  me  a  letter  in  June,  1905,  in 
which  he  said,  *I  don't  believe  it  makes  any  ditference 
whether  you  use  the  word  as  an  adjective  or  a  noun ;  what 
I  said  in  Washington,  was  that  I  was  the  first  person  to 
introduce  the  word  into  dental  nomenclature  when  I  intro- 
duced the  prophylactic  brush  in  1883,  and,  having  first 
made  use  of  the  word  in  that  sense,  I  thought  its  very  use, 
by  virtue  of  priority,  entitled  it  to  be  used  in  this  way.' 

''Dr.  D.  D.  Smith  wrote  me  on  June  10th,  1905,  as  fol- 
lows, 'Dr.  Ehein  is  entitled  to  no  credit  for  original  work 
in  this  matter.  He  never  heard  of  it  or  thought  of  it  until 
I  published  m}"  paper  in  1898.  Propliylactic  refers  to  a 
remedy  and  should  be  used  adjectively.  The  w^ord 
prophylaxis  is  never  used  as  an  adjective  but  as  a  noun, 
the  name  of  a  process.  Prophylaxis  is  not  a  preventive, 
remedy,  but  a  preventive  process.  You  will  find  these 
terms  used  interchangably  in  the  dental  nurse  paper,  and 
without  any  discrimination.' 

"On  June  18th,  1905,  Dr.  Ehein  again  wrote  me;  'Not 
one  patient  out  of  five  hundred  wouhl  understand  your 
purport,  although  they  may  declare  they  do.  I  find  it 
necessary  tc  impress  these  truths  upon  them  again  and 
again  to  make  them  understand.  I  don't  care  a  rap  about 
what  I  call  this  treatment  to  my  patients.  I  believe  that 
what  they  can  understand  most  plainly  is  the  term  to  use, 
therefore,  I  never  say  prophylactic  treatment  or  prophy- 
laxis to  them.  Plain  English  is  the  best  thing  to  use  at  all 
times  with  a  layman.  Therefore,  I  tell  them  that  the 
cleaning  and  polishing  of  their  teeth,  and  massaging  of 
their  gums,  done  frequently,  is  the  best  preventive  treat- 
ment that  we  have  in  dentistry.  It  is  all  very  well  to  use 
these  words  professionally,  but  plain  English  is  the  best 
thing  for  our  patients. ' 

"Dr.  Taylor,  in  discussing  the  name  says,  'Dr.  Harper 
suggested  that  prophylactic  was  a  noun  derived  from  the 


126  Peactical  Oeal  Hygiene. 

Latin.  So  far  he  is  right,  but  he  does  not  go  far  enough. 
It  is  both  a  noun  and  an  adjective,  and  has  been  applied 
to  medicine  for  more  than  two  hundred  years.  What  does 
prophylaxis  mean?  It  is  of  Greek  origin,  derived  from 
a  verb  that  means  to  stand  guard  before.  There  should 
be  a  distinct  meaning  to  our  words,  and  prophylaxis  I 
would  define  as  the  surgical  and  manipulative  treatment 
for  the  preservation  of  health,  and  many  physicians,  with 
Webster,  define  prophylactic  as  a  noun  and  an  adjective, 
meaning  a  medicine  which  preserves  or  defends  against 
disease,  and  the  same  definition  is  given  in  the  Standard 
Dictionary.  Prophylaxis  is  a  noun,  meaning  the  art  of 
guarding  against,  preventing  disease,  observance  of  the 
rules  necessary  to  preserve  health,  preventive  treatment. 
I  believe  the  essayist  intended  to  convey  to  us  the  mean- 
ing of  what  I  would  term  Prophylaxis,  the  surgical  or 
manipulative  treatment  for  the  preservation  of  health, 
and  not  the  rinsing  of  the  mouth  from  time  to  time  with 
medicine  in  the  expectation  of  establishing  the  health  of 
the  mouth,  I  criticised  his  use  of  the  term,  as  I  believe 
he  means  prophylaxis  when  he  says  prophylactic/ 

''Dr.  Harper  says,  'Prophylaxis  is  derived  from  the 
G-reek;  I  did  not  say  it  came  from  the  Latin,  I  said  dis- 
tinctly that  ic,  al,  and  ary  are  Latin  suffixes,  and  that 
prophylactic  is  the  adjective  form  which  means  pertain- 
ing to,  belonging  to,  or  consisting  or  prophylaxis.  Take 
the  word  atmospheric,  which  means  pertaining  to  the 
atmosphere.  You  use  the  adjective  form  with  the  ic 
suffix,  because  you  indicate  samething  that  pertains  to 
atmosphere;  also  hy genie,  as  relating  to  hygiene.  The 
word  prophylactic  is  the  adjective  form  which  is  used  in 
referring  to  the  noun  prophylaxis.  Prophylaxis  is  strict- 
ly the  adjective  form  with  the  ic  termination.  At  most, 
even  if  used  as  a  noun,  as  in  calling  certain  medicines  or 
washes  prophylactics,  it  is  still,  strictly  speaking,  an  ad- 
jective qualifying  the  medicine  or  wash  as'  to  its  uses  and 
purposes,  and  i-ef erring  to  prophylaxis.' 


Definition.  127 

''Leaving  each  indhddual  to  take  liis  choice  between 
these  opposite  opinions,  and  omitting  any  and  all  special 
methods  of  treatment,  I  shall  at  once  introduce  my  sub- 
ject by  the  statement  which  I  believe  will  be  generally 
accepted,  that  nearly  all  our  dental  operations  are  neces- 
sitated by  unclean  and  infected  mouths.    Then  is  it  not 
strange  that  we,  as  dentists,  have  failed  to  keep  those 
mouths  clean?    Is  it  not  strange  that  we  have  treated  this 
abscess,  filled  this  tooth,  operated  for  disease   of  the 
gums,  but  still  think  it  beneath  us  to  clean  the  mouth  and 
keep  it  thus  so  as  to  prevent  these  operations?    I  know 
there  are  many  here  who  will  say  that  they  have  practiced 
cleaning  all  their  professional  lives  and  that  these  things 
will  happen  anyway.    But  the  fact  remains  that  a  thor- 
ough search  has  been  made  of  all  available  dental  litera- 
ture, and  no  mention  of  systematic  prophylactic  treat- 
ment was'  made  up  to  1898.    About  this  year  two  promin- 
ent dentists  began  to  investigate  those  infected  mouths, 
and  to  publish  their  views  and  results.    Still  few  dentists 
took  up  the  work.    In  public  exhibitions  the  actual  re- 
sults were  shown  by  submitting  patients  who  had  been 
under  prophylactic  treatment.    Some  were  enthused  and 
wrote  of  what  they  saw,  but  so  little  progress  was  made 
that  the  originators  nearly  gave  up  hope,  and,  as  one  of 
them  expressed  it,  'went  home  tired,  despondent,  and 
with  the  feeling  that  he  had  done  his  best,  and,  that  as 
the  dental  profession  had  repudiated  his  work,  he  would 
make  no  further  effort.' 

"But  they  kept  at  it,  and  evolved  a  system  of  prophy- 
laxis founded  on  correct  etiologic  iDrinciples.  The  results 
accomplished  have  forced  us  to  realize  the  wonderful 
development  there  is  in  store  along  this  line,  and  we  now 
see  the  dental  journals  teeming  with  some  new  phase  in 
every  issue. 

"In  the  past,  our  work  has  been  the  repair  of  diseased 
tissues ;  our  studies  in  etiology  yielded  no  practical  re- 
sults.    Dentists  of  the  future  must  study  and  practice- 


128  Peactical  Oeal  Hygiene. 

etiology  and  prevention.  Until  our  present  views  on 
oral  prophylaxis  were  accepted  and  understood,  etiology 
was  the  subject  about  which  dental  authors  wrote  volumes 
and  spun  theories  that  now  seem  ridiculous  when  we 
meet  them  in  reading. 

"Detail  would  make  this  paper  too  long,  and  I  shall 
confine  myself  to  facts  which  have  been  well  established. 

"1st,  That  the  etiology  for  the  larger  per  cent,  of 
dental  operations  is  traceable  to  local  infection. 

"2d,  That  tooth  decay  is  from  without,  and  caused  by 
constant  contact  with  infectious  material. 

"3d,  That  simple  gingivitis,  Riggs  Disease,  and  en- 
larged glands,  are  rarely  traceable  to  constitutional 
causes,  as  urema,  or  syphillis,  but  generally  to  an  in- 
fected mouth, 

"If  you  accept  these  well  established  truths,  1  can 
expect  your  interest  in  the  remaining  part  of  this  discus- 
sion. The  medical  profession  has  just  emerged  from  a 
transformation  of  its  methods  from  all  treatment  to  pre- 
vention and  sanitation.  For  instance,  instead  of  giving 
all  their  time  to  the  treatment  of  malaria,  medical  men 
now  turn  to  the  cause,  and,  by  sanitary  measures,  seek 
the  death  of  mosquitoes.  The  up-to-date  physician  now 
watches  the  surroundings  of  his  patients  to  prevent 
typhoid  fever.  He  takes  all  precautions  to  prevent  small 
pox,  scarlet  fever,  and  diphtheria.  'To  cure  is  the  voice 
of  the  past,  to  prevent  is  the  Divine  whisper  of  today. ' 

"Dr.  M.  L.  Rhein,  of  New  York,  and  Dr.  D.  D.  Smith, 
of  Philadelphia,  both  believe  alike  that  this  is  the  most 
important  part  of  a  dentist's  work,  but  they  have  differed 
decidedly  as  to  how  to  put  the  work  into  execution.  Dr. 
Ithein  claims  that  all  patients  should  be  given  the  benefit 
of  Prophylaxis,  but  that  if  he  did  the  work  himself,  he 
would  have  little  time  for  anything  else.  The  charge  for 
the  treatment  would  be  a  burden  for  the  patient  to  pay 
at  the  rate  of  $5.00  to  $15.00  per  hour  for  twelve  treat- 
ments each  vear.     He  contends  that  the  work  is  not  so 


DKFrxniox.  129 

difficult,  but  that  an  assistant  can  soon  learn  to  do  it,  and 
he  has  introduced  to  us  the  dental  nurse,  whose  duty  it 
is  to  jDerform  this  work  for  patients  at  a  nominal  charge. 
Br.  Smith,  on  the  other  hand,  won't  agree  to  any  of  Dr. 
Rhein's  ideas,  and  contends  that  prophylaxis  is  the  most 
difficult  thing  that  the  dentist  can  be  called  upon  to  per- 
form. Inasmuch  as  it  is  the  best  thing  that  a  dentist  can 
do  for  his  patients,  and  takes  a  great  amount  of  skill,  the 
patients  should  not  go  into  the  hands  of  an  assistant, 
but  that  he  must  do  the  work  himself  and  charge  accord- 
ingly. ' ' 


CHAPTEE     XI. 
WHY  IS  PROPHYLAXIS  NEiCESSARY? 

WHEEE   TO  BEGIN  PEOPHYLAXIS. FREQUEIstCY  OF   TEEATMEJJ'T. 

OBJECT  OF  PROPHYLAXIS. 

One  question  which  will  frequently  be  asked  us  is, 
"Wliy  is  prophylaxis  necessary  today  when  all  these 
years  up  to  the  present  time  cleaning  the  teeth  once  a 
year  was  thought  to  be  all  that  was  necessary  T ' 

If  you  will  go  back  a  few  generations,  you  will  find 
conditions  very  different  from  those  of  the  present  day. 
In  the  first  place,  even  those  who  lived  in  the  cities  lived 
more  of  an  outdoor  life.  The  strenuous  life  of  the  mod- 
ern business  man  was  then  unknown.  The  time  for  a 
meal  was  of  much  longer  duration.  In  addition  to  this, 
the  culinary  art  had  not  reached  its  present  high  state  of 
development.  Cooks  in  our  time  seem  to  have  for  their 
chief  object  the  preparation  of  foods  for  absorption 
through  the  intestines,  and  to  dispense,  as  it  were,  with 
the  duties  of  the  stomach.  They  seem  also  to  strive  to 
prepare  the  food  in  as  sticky  a  manner  as  possible.  In 
this  day  and  time,  if  food  were  put  on  the  table  which 
would  require  a  proper  amount  of  mastication,  we  would 
think  that  something  was  surely  wrong,  our  cook  would 
think  it  an  insult  to  our  table,  and  that  such  food  should 
be  run  through  the  meat  chopper.  It  is  a  rare  oppor- 
tunity when  one  of  us  makes  a  meal  of  such  food  that  the 
teeth  get  to  perform  their  real  duties,  that  is,  tearing, 
rending  and  grinding. 

The  interproximal  spaces  in  our  mouths  which  were 
intended  to  be  closed  up,  are  now  wide  open  to  receive 
this  sticky  food.  While  we  have  this  sticky  mass  adher- 
ing to  the  surfaces  of  the  teeth,  it  constitutes  the  best 
pabulum  for  the  growth  of  the  numerous  bacteria  which 
are  always  in  the  mouth. 


Why  is  Prophylaxis  Necessaey?  131 

Disuse  of  any  organ  or  of  any  part  of  the  hocly  results 
in  the  atrophy  of  that  part.  Take  for  example  the  wide 
alveolar  process  with  teeth  embedded  in  thick  peridental 
membrane,  that  our  forefathers  had.  They  were  capable 
of  much  greater  chewing  action  than  are  the  teeth  of  our 
j)resent  day  with  the  thin  peridental  membrane  surround- 
ing the  teeth.  And  then  we  have  that  modern  abnor- 
mality— the  narrow  arches  and  irregular  teeth — making  it 
necessary  to  carry  out  the  most  careful  oral  hygiene  in 
order  to  keep  the  teeth  free  from  stick^^,  doughy,  tenac- 
ious foods.  Also  the  teeth  in  our  present  day  are  sub- 
mitted to  various  deleterious  influences  in  the  way  of  food 
and  drink  condiments  which  are  strong  enough  to  etch  a 
marble  slab,  and  these  are  followed  by  an  ice  cold  drink  or 
steaming  cup  of  coffee.  Thus  we  see  that  cleaning  the 
teeth  was  not  so  necessary  with  our  forefathers  as  it  is 
with  us  on  account  of  the  high  degree  of  civilization^ 
with  its  consequent  dental  degeneracj^,  to  which  we 
have  attained.  We  might  say  that  modern  prophylaxis 
is  to  counteract  this  self  occasioned  loss.  In  other  words, 
we  have  to  do  by  cleaning  the  teeth,  and  prophylaxis 
treatment,  what  used  to  be  done  by  nature.  The  great 
number  of  tooth  manufacturing  houses  throughout  the 
land  points  to  the  necessity  of  finding  some  way  by  which 
this  great  loss  of  such  important  organs  as  the  teeth  can 
be  checked. 

The  medical  profession  has  for  years  advanced  along 
the  lines  of  preventive  or  prophylactic  treatment.  The 
prevention  of  small  pox  has  been  insured  by  vaccination. 
We  have  recognized  the  fact  that  the  best  work  of  our 
medical  men  is  along  the  lines  of  sanitation.  We  have 
welcomed  the  preventive  measures  in  our  army  for  the 
checking  of  malaria  and  typhoid  fever,  and  while  all  these 
are  being  constantly  brought  before  our  eyes,  dentists 
not  quick  to  accept  the  simple  truths  which  are  continual- 
ly in  their  sight,  are  still  making  crowns,  fillings,  and 
bridges  for  these  broken  down  teeth,  and  are  not  recoo;- 


132  Practical  Oral  Prophylaxis. 

nizing  that  the  crown  of  these  teeth  is  not  so  important 
as  the  root,  and  the  peridental  membrane  surrounding  it. 
"When  we  realize  the  nature  and  cause  of  all  these  dis- 
eased conditions,  and  when  a  system  of  preventing  it  is 
at  our  hands,  the  neglect  seems  criminal. 

WHERE   TO   BEGIN   PROPHYLAXIS. 

Our  patients  seem  to  think  that  decay  in  childrens' 
teeth  is  just  a  normal  condition,  for  how  often  will  a 
IDarent  when  told  of  the  decay  in  a  molar  tooth  say,  "0 
that  is  only  a  temporary  tooth,"  and  seem  no  more  to 
mind  it  than  they  would  a  bump  on  the  face,  when  we 
know  that  the  decay  is  serious  because  of  its  bearing  on 
the  future  condition  of  the  child's  teeth 

In  the  first  part  of  the  book  we  have  learned  the  start- 
ling facts  of  what  accumulation  on  the  teeth  leads  to,  and 
the  logical  reason  why  a  systeinatic  removel  should  be 
instituted.  Dentists  should  be  willing  to  give  more  of 
their  time  to  this  work. 


ja-  S<3  <^- 


-^ 


Fig.   is. 

The  necessity  for  and  frequency  of  prophylaxis 
treatment  may  be  illustrated  by  what  I  term  the  Age 
Curve.  "What  is  meant  is,  that  children  at  the  age  of 
six  years  should  be  placed  upon  a  regular  and  systematic 
prophylactic  treatment  for  it  is'  here  that  the  care  of  the 
dentist  is  most  needed.  In  my  practice  I  have  been  aston- 
ished at  the  needless  loss  of  sixth  year  molars.  It  is  for 
this   reason   that   I    say  the   most  important   time   for 


Why  is  Prophylaxis  Necessary?  133 

prophylaxis  is  with  children  at  the  age  of  six  years,  for 
at  this  time  we  can  have  better  control  over  the  patients, 
and  suggest  to  them  habits  which  will  lead  them  into 
];iroper  hygiene  rules.  We  can  thus  have  the  opportun- 
ity, at  the  proper  time,  of  extracting  the  temporary  teeth 
so  that  the  permanent  teeth  will  erupt  at  the  proper 
places.  This  will  save  the  parents  much  orthodontic 
expense,  and  save  these  teeth  from  the  very  start.  At 
this'  time  the  children  learn  the  proper  oral  hygiene,  and 
dental  toilet  habits;  later,  as  they  are  having  to  go  to 
school  or  to  work,  there  will  not  be  a  good  opportunity 
of  getting  these  ideas  instilled  into  their  minds.  From 
the  age  of  twenty-five  to  thirty-five,  there  is  a  period  of 
comparative  immunity,  and  I  would  not  think  that  such 
frequent  prophylaxis  treatment  should  be  necessary. 
After  this  time  some  of  the  work  that  was  done  in  former 
years  begins  to  fail,  and  the  rush  of  business  or  social  life 
makes  great  demands  on  the  vitality,  so  that  more  fre- 
quent treatments  will  prol)ably  be  necessary.  From 
tliirty-five  to  old  age,  more  stress  should  be  laid  on 
prophylaxis. 

In  children  the  main  thing  we  have  to  combat  is  dental 
caries.  I  have  heard  mam''  a  dentist  tell  children  that 
meat  eating  is  the  cause  of  these  decays.  If  Prof.  Miller's 
experiments  are  correct,  he  has  proved  that  meat  eating- 
is  not  the  cause  of  such  decays.  I  believe  that  we  should 
encourage  the  children  to  eat  meat,  and,  what  is  more  im- 
portant, to  leave  off  sticky  foods.  On  the  other  hand,  it 
is  just  as  true  that  as  the  child  grows  older,  these  remains 
of  meat  left  between  the  teeth  become  more  dangerous 
on  account  of  their  tendency  to  cause  pyorrhea.  From 
twenty-five  on,  we  are  not  looking  so  much  to  have  to 
prevent  caries,  for  as  we  have  said,  there  seems  to  be  a 
form  of  immunity  to  caries  at  this  time,  but  the  greatest 
trouble  will  come  from  some  infection  or  disease  of  the 
peridental  membrane,  and  we  must  look  with  all  care 
towards  savino-  this  membrane  in  its  intesritv.     Meat 


134  Peactical  Oral  Peophylaxis. 

impactions,  and  clecompositiou,  cause  mucli  distress 
and  disease  of  the  gum  margin.  The  reason  for  this  is 
that  as  the  patient  grows  older  (as  in  all  other  parts  of 
the  body)  the  alveolar  process  begins  to  undergo  a  senile 
change.  In  the  first  place  the  animal  matter  becomes  less, 
the  bone  begins  .to  solidify,  and  the  blood  vessels  to  get 
smaller.  The  haversian  canal  can  hardly  be  found. 
These  changes  give  food  debris  a  greater  opportunity  to 
irritate  and  infect  the  gums. 

It  was  once  argued  by  some  of  the  medical  profession 
that  the  dentists  did  a  great  wrong  when  they  tried  to 
preserve  a  man's  teeth  after  he  had  passed  the  age  of 
fifty,  for,  said  the  essayist  on  the  subject,  "It  is  nature's 
jjlan  to  lessen  the  amount  of  food  for  the  senile  stomach." 
They  claimed  that  if  the  dentists  kept  the  teeth  of  the  old 
people  up  to  the  standard  that  this  would  enable  them  to 
eat  as  when  young,  and  that  many  of  the  ills  to  which  old 
people  were  subject  were  caused  solely  by  their  being  able 
to  carry  on  active  mastication. 

Dentists,  and  especially  those  engaged  in  prophylaxis, 
now  stand  ready  to  refute  this  from  every  point.  Of 
course,  if  the  joatient  is  one  who  has  a  very  septic  mouth, 
has  bridge  work  which  will  not  be  kept  clean,  and  toxin 
is  generated  around  this,  the  medical  man  has  some  justi- 
fication for  his  belief  that  the  patient  named  be  better  off 
without  any  teeth  at  all,  but  we  have  found  that  the  old 
man  on  prophylaxis  receives  just  as  great  benefits  as  the 
young  person.  This  system  will  not  only  maintain  oral 
cleanliness,  but  prevent,  to  some  extent,  the  atrophy  of 
the  ligament  attachment  of  the  teeth.  Old  people  who  are 
on  this  treatment  are  very  enthusiastic,  and  as  free  from 
general  constitutional  troubles  as  it  is  i^ossible  for  them 
to  be. 

FREQUENCY  OF  TREATMENT. 

In  conclusion,  children  should  be  treated  at  least  once 
a   month,   and  persons   from   twenty-five   to   forty-five, 


Why  is  Prophylaxis  Necessaey?  135 

about  once  in  three  months.    From  forty-five  on  the  treat- 
ment should  be  given  once  a  month. 

Frequently  dentists  on  viewing  the  mouths  of  regular 
prophylaxis  patients  in  my  office,  have  expressed  the 
thought  that  it  did  not  seem  necessary  for  teeth  so  clean 
and  in  such  good  condition  to  have  further  treatment. 
This  is  the  key  note  of  the  whole  situation.  It  would  he 
simply  oral  hygiene  to  clean  the  teeth,  but  here  w^e  have 
something  deeper.  The  patients  on  prophylaxis  come  to 
us  not  for  cleaning,  but  for  the  results  in  the  true  meaning 
of  prophylaxis — the  guarding  of  the  oral  cavities  from 
the  entrance  of  infection  which  would  in  any  way  get  into 
the  teeth  and  mouth.  In  prophylaxis,  we  pre-suppose 
that  all  adhesions  have  been  removed,  that  the  treatment 
will  be  directed  to  those  places  which  the  patients  them- 
selves cannot  reach,  and  all  tendency  towards  any  path- 
ological condition  has  been  eradicated. 

OBJECT  or  PROPHYLAXIS 

The  claim  of  Smith,  that  the  peridental  membrane  is 
of  more  importance  than  the  crown  of  the  tooth,  has  been 
borne  out  by  investigation  of  the  origin  of  pyorrhea,  and 
the  quicker  this  is'  recognized,  and  the  quicker  we  diag- 
nose any  inflammation  at  the  gingival  margin  of  tlie 
peridental  membrane,  the  more  certain  we  will  be  of  free- 
ing our  patient  from  any  possible  danger.  There  is  some 
doubt  whether  there  is  ever  a  reattachment  of  the  perice- 
mental fibres  after  they  have  once  been  detached  by  dis- 
ease. This  emphasized  the  necessit}''  of  prophylaxis  as  a 
preventive  of  pyorrhea. 

We  have  learned  that  the  caries  of  the  teeth  are  de- 
pendent for  the  most  part  upon  two  formations,  the  carbo- 
hydrates' and  micro-organisms.  As  neither  of  these  fac- 
tors can  be  eliminated,  all  that  we  can  do  is  to  learn  as 
much  as  possible  how  to  hold  either  or  both  of  these  ele- 
ments in  check.    Unfortunatelv,  the  vcrv  articles  of  which 


136  Practical  Oral  Prophylaxis. 

vre  eat  most  freely,  that  is,  pastry,  candy,  etc.,  give  tlie 
largest  percentage  of  carbohydrate  and  acid  units. 

As  it  is  difficult  at  the  present  time  to  control  the  mat- 
ter of  diet  the  object  of  prophylaxis  should  be  to  elimi- 
nate as  far  as  possible  the  effects,  and  certainly  the  first 
question  to  be  taken  up  is  that  of  logihiUtii.  Thus  we  find 
that  those  substances  which  are  either  alkaline  or  neutral 
in  effect  are  chocolate,  biscuit,  milk,  dates,  etc.,  while 
substances  such  as  potatoes,  lemons,  pine  apples,  nuts 
and  meats,  being  originally  acid  in  reaction,  are 
beneficial. 

The  conclusions  which  are  reached  by  Pickerill  after 
considerable  experiments  along  this  line  are: 

''That  in  order  to  prevent  the  retention  of  fermant- 
able  carbohydrates  on  and  between  the  teeth,  and  so 
eliminate  or  very  considerably  reduce  the  carbohydrate 
factor  in  the  proportion  of  caries,  starches  and  sugars 
should  on  no  account  ever  be  eaten  alone,  but  should  in 
all  cases  either  be  combined  with  a  substance  having  a 
distinctly  acid  taste,  or  they  should  be  followed  by  such 
substances  as  have  been  shown  to  have  an  'alkaline  potem 
tial,'  and  the  best  of  these  are,  undoubtedly,  the  natural 
organic  acids  found  in  fruit  and  vegetable." 

Those  races  where  comparative  immunity  from  decay 
is  found,  undoubtedly  produce  the  result  by  the  con- 
stant use  of  salivary  stimulants  producing  in  the  salivary 
glands  a  constant  activity  Avhich  prevents  stagnation  in 
the  oral  cavities,  and  thus  preventing  pre-disi)osition  to 
decay. 

Several  references  have  been  made  heretofore  to  the 
softness  and  stickiness  of  our  foods  which,  lodging  be- 
tween the  teeth,  give  a  start  towards  caries.  The  child's 
taste  is  a  guide  which,  instead  of  giving  heed  to,  we  have 
always  sought  to  ignore.  The  child  naturally  calls  for 
the  articles  of  diet  having  an  acid  reaction,  fruits,  salads, 
candies,  etc.  The  harm  does  not  come  to  the  child's  teeth 
from  these  substjinces,  but  from  the  form  in  which  they 


Why  is  Peophylaxis  Necessaky?  137 

are  eaten — ^sticky,  doughy  cake  for  example,  sticks  be- 
tween the  teeth  and  stays  for  future  decomposition.  I 
have  no  doubt  that  candy  in  the  pure  state  is  not  only 
non-detrimental,  but  of  great  food  value,  and  a  preventer 
of  decay.  Dr.  S.  A.  Visanska,  a  pediatrist  of  Atlanta, 
read  a  paper  before  the  Georgia  State  Dental  Society, 
in  which  he  said : 

"From  time  immemorial  it  has  been  handed  down  to  us  as  an 
axiomatic  decree  that  the  eating  of  candy  or  other  sweets  does  have  a 
direct  eifect  on  the  teeth  causing  rapid  decay  and  thereby  preventing 
the  proper  grinding  of  food  and  eventually  causing  stomach  or  intestinal 
troubles  Avith  all  the  myriad  dangers  attendant  on  malnutrition. 

"I  have  considered  carefully  what  candy  eating  really  does  for 
the  teeth,  and  apart  from  the  hard  stick  candy  which  might  injure  the 
cutting  surfaces  of  the  teeth,  or  the  tough  chewing  candy  which  might 
have  a  similar  effect  by  dulling  the  surfaces  exposed  to  it,  it  does  not 
seem  probable  to  me  that  further  injurj^  could  be  done  to  the  hard 
enamel  hy  actual  contact  with  sweets.  We  have  been  told,  however, 
that  often  the  solution  of  sugar  or  glucose  of  which  the  average  candy 
is  made,  causes  a  process  of  fermentation  which  results  in  lactic  acid 
and  that  this  acid  does  attack  the  enamel  and  acts  directly  upon  it 
thus  causing  decay  by  injuring  this  hard  surface  and  hence  exposing 
the  dentine,  which  is,  in  turn,  similarly  attacked  until  at  last  the  vital 
structure  of  the  tooth  is  reached. 

"But  now  let  us  see  what  actually  happens  when  glucose  or  sugar 
does  ferment  in  the  mouth.  If  the  sugar  or  glucose  is  held  in  the 
mouth  long  enough  at  the  normal  temperature  of  the  mouth  which  is 
98. 6  degrees  this  fermentation  will  produce  C  0,  and  alcohol,  and 
later  acetic  acid.  Now  alcohol  is  really  a  perservative  and  therefore 
C  Oo  must  be  the  dangerous  element.  But  can  this  be  true?  As  a 
matter  of  fact  there  is  absolutely  no  evidence  in  support  of  the  destruc- 
tive quality  of  carbon-dioxide  and  even  if  this  apparently  harmless  gas 
could  effect  the  teeth  there  is  still  another  reason  why  its  dangers  are 
minimized.  We  all  know  that  after  eating  sweets  we  get  very  thirsty 
and  usually  take  water  immediately,  thus  diluting  the  sugar  which  may 
remain  in  the  mouth.  The  reason  for  this  thirst  is  that  sugar  has  so 
great  an  aflBnity  for  water  that  as  soon  as  it  reaches  the  stomach  water 
is  taken  up  by  a  process  of  dialysis  through  the  walls  of  the  stomach 
and  Nature  to  comi^ensate  for  this  demand  and  the  consequent  defi- 
ciency of  fluid,  demands  water  through  the  mouth.  The  result  is  that 
the  ample  washing  of  the  mouth  after  eating  sugar  would  seem  to  point 
to  yet  another  reason  against  the  theory  of  tooth  decay  from  contact. 

''It  has  also  been  determined  by  testing  with  litmus  paper  that  in 


138  Peactical  Oral  Peophylaxis. 

from  one  to  six  hours  after  eating  sweets  the  influence  of  this  acid,  even 
if  it  should  be  harmful,  had  disappeared  for  there  is  no  trace  of  it  in 
the  mouth  within  the  period  of  time  mentioned.  Acetic  acid,  howevei% 
does  not  have  any  effect  on  the  enamel,  this  I  have  proven  by  actual  test. 

"Lactic  acid  in  appreciable  quantities  will  attack  the  enamel  of 
the  teeth  causing  a  jelly-like  substance  to  form  thereon.  But  the  lactic 
acid  foods,  such  as  butter-milk  as  well  as  many  of  the  present  day  foods 
which  are  prepared  from  lactone  ingredients  are  too  weak  in  lactic 
acid  to  have  any  direct  effect. 

"The  effect  of  a  solution  of  lactic  acid  of  the  proportion  of  one 
dram  to  the  ounce,  when  applied  to  a  tooth  I  have  proven  hy  direct 
experiment. 

"Of  course  I  know  there  are  many  stomach  troubles  which  might 
result  in  acid  formation  in  the  mouth  which  directly  injure  the  teeth 
and  such  conditions  might  possibly  result  from  excess  of  sweets  in  the 
stomach  or  from  other  dietetic  indiscretions — ^but  that  contact  in  the 
mouth  with  even  the  excessive  quantities  of  sweets  which  the  normal 
child  craves,  does  not  appeal  to  me  as  a  logical  reason  for  decayed  teeth." 

These  facts  are  borne  out  by  later  day  experimenta- 
tion in  tbe  examinations  for  defects  in  the  child's  teeth. 
We  may  well  consider  the  food,  and  lunches  furnished  to 
the  children  as  a  probable  cause  for  these  defects,  in  that 
most  of  the  meals  are  made  up  of  salivary  depressants. 
Added  to  this  fact,  we  must  remember  that  the  debris 
stays  around  the  teeth,  and  between  them  until  the  next 
meal.  The  child's  prophylaxis  should  begin  by  recom- 
mending to  the  child  or  his  parents  the  addition  of  more 
fruit  to  his  diet,  and  that  this  fruit  be  eaten,  not  before 
the  meal,  but  after  it  in  order  that  the  salivary  glands 
may  become  excited,  and  remain  so  until  the  debris  is 
rendered  soluble  or  washed  away  by  the  flow  of  saliva. 
We,  as  dentists,  formerly  thought  that  salads  and  condi- 
ments were  very  detrimental  to  our  patients'  teeth. 
However,  used  in  the  right  way,  there  can  be  no  detri- 
mental action. 

Tea  is  one  of  the  salivary  depressants,  and  should 
not  be  given  to  children  at  all;  if  our  grown  up  patients 
use  it,  we  should  insist  that  they  do  not  end  a  meal  with 
this  drink,  but  use  it  in  the  first  part  of  the  meal,  for,  used 
in  the  later  part  of  the  meal  or  with  the  desert,  it  stops 


Why  is  Peophylaxis  Necessaey?  139 

the  flow  of  saliva  for  some  time,  allowing  the  micro-or- 
ganisms of  the  month  to  multiply  at  a  great  rapidity. 
Some  one  has  said  that  were  lemonade  drumk  as  a  unver- 
sal  beverage  it  would  be  impossible  to  have  typhoid  fever. 
This  alone  is  a  recommendation  for  this  most  excellent 
beverage,  but,  when  we  couple  to  this,  the  fact  that 
fruit  acid  is  one  of  the  greatest  salivary  stimulants,  we 
should  not  fail  to  take  advantage  of  its  beneficial  qualities. 
All  this  leads  us  to  the  fact  that  the  aid  we  secure 
from  nature  in  the  prevention  of  caries,  must  be  through 
increasing  the  activity  of  the  nerves  leading  to,  and 
having  control  of,  the  salivary  glands.  These  being 
brought  to  their  highest  development,  we  have  a  prophy- 
lactic fluid  far  superior  to  any  thing  that  can  be  made 
artifically.  We  can  accomplish  by  mouth  washes  and 
dentrifices  some  things  (dealt  with  in  a  later  chapter) 
but  let  us  start  off  our  prophylaxis  with  the  knowledge 
of  the  fact  that  nature  has  this  great  preparation  ready 
to  manufacture  at  our  suggestion. 


CHAPTEE     XII. 
THE  PEOPHYLAXIS   CLASS. 

PRELIMHsTARY   WORK   BEFORE   EISTTERIISTG   PATIENT   ON   PROPHY- 
LAXIS.— PROPHYLAXIS    TECHNIC. — VIEWS    OP    KELLY, 
HOWES   AND   GOBLE. 

When  we  have  finislied  our  dental  work,  and  have 
taught  our  patient  the  importance  of  oral  hygiene,  the 
question  wMoli  will  be  asked  the  doctor  is,  ^'Now  doctor, 
what  can  I  do  to  keep  my  mouth  in  this  condition,  and 
how  often  must  I  come  back  for  examination?"  If  the 
facts  and  argTimnts,  which  have  been  brought  forward  in 
this  book,  have  been  of  interest  to  you,  it  is  hoped  that  you 
will  start  what  I  call  the  "Prophylaxis  Class."  This  is 
somewhat  original  with  me.  I  tell  my  patients,  that  if 
they  are  serious  in  their  desires,  I  will  take  them  at  a 
nominal  fee  for  one  year,  and  if  they  will  agree  to  come 
as  often  as  I  think  necessary  to  keep  their  mouths  in 
perfect  condition.  There  is  no  use  to  advise  patients  to 
go  on  prophylaxis  while  you  have  reason  to  believe  that 
they  will  not  carry  out  your  instructions,  for  it  is  a  waste 
of  time  and  embarrassing  at  the  end  of  the  year  to  find 
that  the  patient's  mouth  is  in  no  better  condition  in  spite 
of  all  your  work.  Many  times,  however,  I  have  seen  a 
gawky  boy  who  was  a  perfect  stranger  to  a  tooth  brush, 
after  six  months'  of  this  treatment,  acquire  oral  hygiene 
habits  which  he  would  follow  all  his  life.  Young  girls 
would  probably  be  the  best  to  enter  upon  this  treatment 
in  beginning  this  work.  I  do  not  want  any  one  to  enter 
the  class  on  the  first  blush  of  enthusiasm.  I  generally 
give  them  a  reprint  on  the  subject  to  take  home  and  read. 
My  policy  of  educating  patients  is  to  select  some  good 
article  appearing  in  dental  journals,  and  secure  from  the 
author  the  necessary  reprints.  I  have  always  found  the 
author  glad  to  supply  them.    Then,  if  they  are  willing  to 


The  Prophylaxis  Class.  141 

fulfil  the  demands  made  on  them,  I  gladly  place  them 
upon  the  list.  One  of  the  worst  difficulties  in  getting 
the  joatient  ready  for  prophylaxis  is  the  banded  crowns, 
and  cement  and  gutta  percha  fillings.  These  necessitate 
considerable  dental  work.  We  should  have  some  every- 
day illustration  to  use  in  explaining  to  the  patient  the 
necessity  for  having  this  work  done,  in  order  to  show 
them  that  it  gives  lodgment  for  debris  which  would  over- 
come all  our  efforts  at  prophylaxis'. 

PEELIMINARY    WORK    BEFORE   ENTERING   PATIENT    ON 
PROPHYLAXIS. 

Before  the  treatment  is  begun  all  dental  work  must  be 
brought  up  to  the  standard.  All  roots  of  teeth,  which 
cannot  be  saved,  must  be  extracted.  All  meat  holes  and 
fillings  with  bad  contours  must  be  corrected.  All  tarter 
must  be  removed,  and  the  teeth  put  in  a  hygenic  condi- 
tion as  described  under  ''Cleaning  Teeth."  AH  this,  of 
course,  must  be  paid  for  at  regular  fees,  for,  as  I  have 
said  before,  prophylaxis  presupjDoses  a  perfectly  clean 
mouth. 

Fones  gives  the  illustration  of  two  pieces  of  glass  each 
five  inches  square.  One  of  these  is  ground,  and  the  other 
polished  plate  glass.  Both  are  smeared  over  with  the 
debris  which  we  would  find  in  the  average  mouth.  With 
one  sweep  of  the  tooth  brush  it  is  easy  to  clean  the 
polished  surface,  while  it  takes  several  motions  to  clear 
the  ground  glass  surface.  Another  illustration  is  the 
cement  slab  at  our  chairs.  When  this  has  become  scratch- 
ed or  rough,  we  find  difficulty  in  removing  the  cement  left 
over  from  our  operation.  On  the  other  hand,  when  the 
slab  is  new  and  free  from  these  defects,  it  may  be  cleaned 
by  simply  placing  it  in  water  and  wiping  off  the  cement. 
Now  the  same  thing  holds  true  in  the  mouth.  If  the 
patient  is  on  prophylaxis  and  the  teeth  kept  in  the  proper 
state  of  polish  by  the  monthly  treatments,  he  can  with  one 
sweep  of  the  brush  remove  any  deposit  Avhich  may  have 


142  Pkactical,  Oe.u.  Peophylaxis. 

settled  on  the  teeth,  but  if  this  food  debris  is  held  by  ac- 
cimiulations  of  tarter,  as  found  in  the  average  mouth,  it, 
can  only  be  removed  by  a  dentist. 

PEOPHYLAXIS  TECHNIC. 

A  few  years  ago  at  one  of  the  state  societies  where  I 
was  giving  a  clinic,  a  countrified  looking  dentist  pushed 
himself  to  my  side  and  said,  "What  the  devil  is  a  lorophy- 
laxis  treatment  any  how?  One  of  your  patients  moved 
to  my  town  and  insisted  that  I  give  her  a  prophylactic 
treatment.  I  wrote  to  you  to  find  out  what  it  was,  but 
the  answer  must  not  have  been  correct  as  I  gave  her  a 
treatment  and  she  never  returned."  An  explanation  of 
the  conditions  which  necessitate  prophylaxis  makes  a 
much  greater  impression  than  the  statement  of  the  simple 
technique  necessary  to  bring  about  the  results.  In  the 
art  gallery,  we  stand  enthralled  before  some  master 
painting,  we  live  with  the  person  or  in  the  scene  which  it 
depicts,  and  enter  into  the  vision  which  caused  the  picture 
to  be  painted.  Had  we  been  in  the  studio  where  this 
work  was  done,  we  would  probably  not  have  shown  any 
interest  in  the  small  brushes  and  palletts  of  paint  with 
which  the  artist  made  the  picture.  Thus  I  have  found 
that  I  could  interest  dental  students  and  keep  up  their 
enthusiasm  until  I  began  the  description  of  the  technique. 
They  expected  something  big,  and  when  I  told  them  of 
its  simplicity,  the  enthusiasm  had  a  tendency  to  drop. 
The  technique  of  Prophylaxis  is  nothing  more  than  the 
technique  of  cleaning  the  teeth,  only  carried  out  to  a 
much  greater  nicety,  and,  in  addition,  the  regularity 
with  which  it  is  carried  out.  One  prophylactic  treatment 
will  not  amount  to  much,  but  the  effects  of  a  half  dozen 
of  these  treatments,  each  one  overcoming  some  defect, 
makes  a  vast  difference  between  these  two  operations. 
Dr.  Henry  A.  Kelley  of  Portland,  Me.,  says: 
"In  beginning  our  spraying  and  polishing,  the  first 
condition  that  confronts  us  is  a  viscid  coating  of  saliva. 


Peophylaxis  Technic.  143 

and  gelatinous  plaques  that  covers  tlie  teeth  and  gums. 
First  take  a  tube  of  rather  hot  water,  of  about  150°  F., 
to  which  has  been  added  one  dram  of  aromatic  spirits  of 
ammonia.  The  alkalinity  of  this  spray,  applied  under  a 
pressure  of  from  35  to  50  pounds,  will  overcome  this 
viscidity.  After  thorough  spraying  with  this  first  spray, 
alternate  with  a  second  spray,  composed  of  three-quar- 
ters of  a  tube  of  warm  water  and  one-quarter  of  a  tube 
of  some  of  the  forms  of  hydrogen  dioxid.  To  this'  tube 
add  a  few  drops — three  or  four — of  essence  of  anise  to 
disguise  the  very  unpleasant  hydrogen  dioxid  taste.  This 
second  spray  is  used  on  account  of  its  cleaning  effect.  As 
the  doxid  comes  in  contact  with  the  decaying  particles  of 
animal  matter  we  have  the  well-known  boiling  effect, 
which  tends  to  lift  out  and  off  all  foreign  matter  accumu- 
lated around  the  teeth.  Then  with  a  hand  porte-polisher 
(I  use  Harrell's)  charged  with  flour  of  pumice  begin  the 
polishing.  The  pumice  must  be  moistened  with  water  to 
make  a  paste  not  too  thin,  to  which  two  or  three  drops  of 
essence  of  peppermint  are  added.  The  peppermint  serves 
not  alone  to  take  away  the  sandy  taste,  but  also  to  exert 
a  cooling  effect  on  the  gums,  and  leaves  a  refreshing  and 
clean  taste  in  the  patient's  mouth  after  the  operation  is 
finished.  I  usually  go  over  all  the  teeth  in  a  rather 
hurried  way  in  order  to  first  get  rid  of  any  matter  adher- 
ing to  the  surfaces,  and  then  after  another  spraying, 
alternating  with  both  sprays,  I  pass  to  the  last  tooth  on 
the  upper  left  side  and  go  over  all  the  buccal  and  labial 
sides  of  all  the  upper  teeth,  going  into  the  approximal 
spaces  as  well  as  pos'sible  with  the  porte-polisher.  Use 
flattened  orange-wood  points  for  the  flat  surfaces,  apply- 
ing considerable  force  with  a  circular  movement  directed 
from  the  neck  to  the  cutting  edge  and  just  under  the  gum 
margin.  This  giim  margin  is  a  very  important  region, 
and  it  is  probable  that  if  this  is  kept  well  polished  your 
patient  will  never  have  pyorrhea,  or  if  he  has  had  it,  it 
will  never  return.    Having  gone  around  to  the  last  tooth 


144  Peactical,  Oral  Prophylaxis. 

on  the  upper  right  side,  spray  again  with  the  second 
spray,  and  return  to  the  last  tooth  on  the  upper  left  side, 
going  over  the  lingual  surfaces  and  then  spraying  with 
the  second  solution.  Then  polish  your  grinding  surfaces. 
The  same  process  is  followed  with  the  lower  teeth.  Go 
over  all  exposed  surfaces'  with  your  porte-polisher 
charged  with  tin  oxid  made  into  a  paste,  which  will  im- 
part a  beautiful  polish  to  these  surfaces.  Tlhen  apply  a 
thorough  spraying  with  a  third  solution,  which  consists 
of  one-half  a  tube  of  hot  water  to  which  has  been  added 
one-half  a  tube  of  some  pleasing  general  mouth-wash  (I 
use  Alkalyptol,  which  I  find  very  satisfactory ;  not  all 
antiseptic  mouth-washes  leave  the  same  refreshing  taste 
in  the  mouth),  and  pass  waxed  floss  silk  between  all  the 
teeth  and  clean  out  the  interproximal  spaces,  spraying 
with  the  second  solution  as  necessary.  After  that  finish 
with  the  third  spray,  finally  allowing  a  rinsing-out  with  a 
glass  of  cool  water.  If  your  work  has  been  thorough, 
your  patient  has  the  first  sensation  of  what  a  clean  mouth 
means.  Patients  often  tell  me  that  they  hate  to  go  home 
and  eat  and  soil  the  mouth  again. 

"It  is  well  to  alternate  from  month  to  montb,  taking 
the  upper  teeth  first  in  one  month  and  the  lower  teeth  first 
the  next  month.  I  find  that  for  some  reason  which  I 
cannot  explain,  the  upper  teeth  respond  to  treatment, 
especially  in  pyorrhea  cases,  much  more  readily  than  the 
lower  ones,  and  I  have  these  two  thoughts  to  offer  in  this 
connection.  I  find  that  when  I  begin  with  the  upper  teeth 
I  often  spend  forty  minutes  going  over  them,  which 
leaves  me  but  twenty  minutes  of  the  hour  appointed  for 
the  lower  ones;  hence  the  practice  of  alternating  from 
month  to  month.  The  pumice  also  becomes  much  thinner 
from  the  admixture  of  saliva  in  polishing  the  lower  teeth. 
I  often  use  the  saliva  ejector  or  napkins  to  offset  this  lat- 
ter condition,  but  I  cannot  as  yet  say  with  what  result.  As 
you  first  begin  to  polish  with  the  pumice,  your  wood  point 
will  slip  over  the  tooth,  and  there  will  be  a  slimy,  greasy 


Peophylaxis  Techxic.  145 

sensation.  But  as  yon  polish  and  polisli,  you  get  down 
to  the  clean  tooth-surface,  and  then  you  experience  that 
squeaky  sound  that  indicates  a  clean  tooth-surface.  The 
slimy  substance  that  you  are  removing  is  composed  of 
the  gelatin-forming  micro-organisms,  which  I  shall  ex- 
plain later  in  a  quotation  from  Johnson.  Hence,  if  you 
make  every  filling  smooth,  allow  no  shoulder  or  lodging- 
place  for  the  decay-producing  germs  to  remain,  and  then 
destroy  the  gelatinous  film  under  which  the  micro-organ- 
isms that  cause  decay  are  enabled  to  effect  their  destruc- 
tive process,  you  render  it  extremely  hard  for  decay  to 
begin  or  make  progress." — From  Dental  Cosmos. 

Dr.  Kelley  suggests  the  use  of  a  nasal  spray  tip,  made 
b}^  Debilbiss  Co.,  which  he  uses  to  spray  out  the  inter- 
proximal space  from  the  buccal  side.  Place  the  index 
finger  just  over  it  (that  is  above  it,  on  the  upper,  towards 
the  root  end)  draw  it  back  just  a  little  and  spray.  The 
spray  thus  goes  beyond  the  tooth  and  out  on  the  palatal 
side.  Following  this  suggestion  Dr.  Kelley  says,  "The 
patients  realize  how  you  have  cleaned  the  teeth. ' ' 

The  difference  between  my  present  technique,  and  Dr. 
Kelley 's  is  that  at  each  operation  the  first  thing  done  is 
with  a  small  scaler  of  the  Younger  type  (which  has  had 
its  sharp  edge  removed)  to  gently  insert  it  under  the  free 
margin  of  the  gum,  and  to  circle  the  entire  gingival  por- 
tion, being  careful  to  exert  no  force  on  the  instrument 
which  would  in  any  way  tear  the  attachment  at  the  peri- 
dental margin.  I  consider  this  the  most  important  part  of 
prophylaxis,  for  it  is  this  membrane,  above  everything 
else,  which  we  must  protect.  It  is  here  that  the  begin- 
nings of  deposits  may  be  detached  in  their  incipiency. 
No  porte  polisher  or  pumice  will  do  this;  only  skilled 
touch  and  the  proper  instrument  can  do  it. 

The  mouth  in  which  there  has  once  been  a  pyorrheal 
condition  will  often  call  for  a  fine  point  of  judgment,  for 
it  is  often  necessary  to  enter  forcibly  into  these  former 
pyorrhea  pockets,  and  clean  them  out  thoroughly.    This, 


146  Pkactical  Oral  Peophylaxis. 

if  riglitly  clone,  can  do  no  possible  harm.,  and  certainly  is 
the  means  of  preventing  future  eruptions  from  some 
infection  forcing  its  way  into  these  places.  If  this  is 
done,  every  three  or  four  months,  it  will  in  time  do  more 
to  eliminate  this  scar  than  any  other  treatment.  It  seems 
that  with  each  treatment  the  pockets  get  shallower. 

After  this,  I  differ  with  Dr.  Kelly  as  to  the  manner  of 
using  the  dental  floss  silk.  He  uses  it  last.  I  use  it  im- 
mediately after  instrumentation  for  the  reason  that  at 
this  time,  the  mouth  has  no  accumulation  of  powdered 
pumice,  which  would  make  it  most  difficult  to  pass  silk 
between  the  teeth.  Do  not  put  the  abrasive  on  the  silk, 
and  then  attempt  to  pass  it  between  the  teeth.  Pass  the 
silk  in  first,  and  then  place  on  a  small  amount  of  abrasive. 
The  same  procedure  is  repeated  at  each  interdental 
space.  The  largest  and  broadest  floss  silk  that  can  be 
passed  between  the  teeth  should  be  used ;  this  is  the  dan- 
ger line  at  which  we  make  our  greatest  fight  against 
caries,  and  the  simple  running  of  the  floss  silk  between 
the  teeth  will  not  accomplish  the  desired  results.  Accord- 
ing to  later  investigations  by  Pickerill,  it  might  be  better 
to  substitute  for  the  spray  containing  aromatic  spirits  of 
ammonia,  to  overcome  the  viscidity  of  the  saliva,  some 
vegetable  acid  spray  should  be  used  which  will  not  only 
give  an  increased  flow  of  saliva,  but  will  furnish  the  pro- 
tective qualities  which  it  possesses,  and  will  remain  for 
some  time  after  the  prophylaxis'  treatment;  this  flow  of 
saliva  is  undoubtedly  inhibited  b}^  an  alkaline  spray. 

Dr.  Gillette  Hayden  called  my  attention  to  the  use  of 
powdered  sodium  citrate  for  the  removal  of  mucus  col- 
lections. Dr.  Cook,  of  Chicago,  endorsed  it,  claiming  that 
it  attacks  only  organic  substances,  without  detriment  to 
the  teeth  or  the  soft  tissues.  It  can  be  used  at  the  chair 
in  connection  with  the  abrasive  used  in  the  treatment,  but 
must  not  come  in  contact  with  any  moisture  previous  to 
the  time  of  using  it.  Use  it  with  water  instead  of  any 
other  fluid  as  it  combines  readily  with  other  substances. 


Prophylaxis  Techxic.  147 

An  admirable  adjunct  for  prophylaxis  treatment  as 
advised  by  Dr.  Minnie  Masters  Howes,  of  Minneapolis, 
is  giving  much  attention  to  massage  and  spraying : 

"I  massage  the  gums;  showing  the  patient  how  it  is 
done  and  instructing  him  to  do  this  about  five  minutes 
each  day,  as  long  as  it  is  necessary.  I  use  the  thumb  and 
first  finger,  catching  as  high  up  on  the  gums  as  possible, 
the  finger  on  the  labial  and  thumb  on  the  lingual  surface 
and  pull  down  over  the  teeth,  gently  at  first,  if  the  gums 
are  sore  and  more  vigorously  as  they  become  harder.  Re- 
verse the  motion  for  the  lower  teeth.  This  will  make 
the  gums  hard  and  firm  and  start  up  a  healthy  circula- 
tion. It  will  also  check  recession  of  the  gums  if  persisted 
in,  and,  in  many  cases,  will  pull  them  back  to  their  nor- 
mal position  about  the  teeth.  The  teeth  and  soft  tissues 
of  the  entire  oral  cavity  are  now  sprayed  with  an  antisep- 
tic wash  under  heavy  air  pressure,  forty  or  fifty  pounds. 
The  spray  is  directed  into  all  pockets,  distending  them 
and  washing  out  all  pumice  and  debris;  the  teeth  are 
thoroughly  washed,  especial  attention  being  directed  to 
the  free  gingival  gum.  margins,  the  tongue  and  mucous 
lining  of  the  mouth  are  cleansed  with  the  greatest  care 
and  circumspection.  This  phase  of  the  treatment  is  the 
one  most  appreciated  hj  the  patient.  The  sense  of  cool 
cleanliness  left  in  the  mouth  by  the  spraying  is  something 
that  must  be  felt  to  be  appreciated. 

''After  the  first  treatment,  the  gums  are  apt  to  be  sore, 
so  I  have  the  joatient  use  bicarbonate  of  soda.  Take  a 
teaspoonful  in  a  third  of  a  glass  of  warm  water  and  rinse 
the  mouth  often  until  soreness  in  the  gums  has  disap- 
peared. Give  the  patient  all  the  instruction  you  can  in 
the  proper  care  of  the  mouth  and  teeth,  and  when  they 
return  for  their  next  treatment,  point  out  the  places,  if 
any,  they  have  missed.  If  it  is  a  very  bad  case,  I  have  the 
patient  return  in  a  week  for  another  treatment.  Then 
after  that,  once  a  month  is  usually  often  enough,  although 
there  are  cases  that  every  two  weeks  would  not  be  too 
often  to  see. ' ' 


148  Peactical  Oeal  Peophylaxis. 

As  opposed  to  this  system  of  monthly  prophyhixis, 
is  that  of  Dr.  L.  S.  Groble,  of  Rochester,  N.  Y.,  who  writes 
of  his  technique  in  a  recent  number  of  the  ''Dental  Dis- 
pensarj^  Record."  He  prefaces  his  remarks  by  saying 
that  for  twenty  years  he  has  been  doing  prophylaxis  work 
in  spite  of  uric-acid  and  rheumatic  diatheses,  and  found 
that  the  only  way  to  properly  carry  out  prophylaxis  was 
to  remove  the  tarter,  and  keep  the  mouth  clean.  He 
further  says  that  he  is  not  in  sympathy  with  the  so 
called  "Prophylaxis  Movement." 

"Like  the  cry,  'On  to  Richmond,'  we  yell,  'Remove 
the  Plaques,'  and  so  the  whole  mouth  is  scrubbed  and 
the  gums  are  punched  and  stain  is  used,  all  on  the  basis 
that  a  micro-organism  is  the  cause  of  caries,  although  it 
has  not  been  isolated  and  the  theorj  has  not  been  proved. 
Do  the  plaques  stay  removed?  No,  they  return  in  full 
force  in  six  hours  and  in  some  peoples  mouths  in  two 
hours,  showing  that  the  micro-organisms  are  always  there 
and  rightfully  there.  You  may  ask,  'What  do  you  say 
then!  Let  the  plaques  alone?'  No,  I  say  remove  them 
in  so  far  that  you  do  not  injure  the  gum  tissue  and  only 
that  far.  And  this  putting  stain  on  the  teeth  and  then 
tearing  the  mouth  to  pieces  getting  it  off,  just  to  show 
the  patient  where  the  plaques  are,  I  consider  a  mistake 
or  worse.  And  to  have  all  your  patients  come  once  a 
month  for  prophylaxis  is  rank  nonsense,  and  I  have  seen 
many  evil  effects  from  it.  I  have,  and  you.  have  patients 
whose  mouths  after  three  months  have  no  more  plaques' 
than  other  patients  have  after  six  hours.  The  former 
under  the  monthly  rule,  you  would  rob,  the  latter  you 
would  1)6  neglecting.  I  have  patients  that  come  year  after 
year  and  who  need  no  oral  prophylaxis  and  yet  I  have 
no  doubt  that  I  could  show  plaques.  I  do  not  believe  that 
plaques  cause  decay,  but  as  a  media  for  the  acid  of  fer- 
mentation going  on  in  the  mouth  they  may  cause  one  per 
cent.,  I  doubt  if  it  is  more." 


CHAPTER     XIII. 

INSTRUMENTS  AND  POLISHING  MATERIALS 
USEFUL  IN   PROPHYLAXIS. 

Autliorities  are  not  agreed  as  to  what  constitutes  the 
iustrumentation  for  prophylaxis.  Some  advise  against 
the  use  of  anything  like  a  scaler,  while  others  advise  the 
regular  use  of  delicate  scaler  under  the  free  gum  margin, 
and  reopening  and  cleaning  out  old  pyorrhea  jDockets  at 
frequent  intervals. 

The  condition  before  treatment,  and  present  state, 
together  with  a  full  understanding  of  the  normal  and 
pathological  picture  presented  by  each  case,  must  govern 
the  operator  on  this  question. 

Instrumentation  used  with  a  proper  knowledge  of  the 
demands  of  true  prophylaxis  treatment  can  only  be  pro- 
ductive of  good.  Whatever  points  selected  and  used 
should  have  the  sharpe  edges  removed. 

The  various  shapes  of  spoon  excavators  cap.  be  made 
into  most  excellent  instruments  by  removing  the  edge 
with  a  stone.  Many  of  the  instruments  hereafter  de- 
scribed for  pyorrhea  work  are  also  useful  in  prophylaxis. 
Numbers  3,  4  and  15  of  the  Good  set  have  been  of  great- 
est use  to  the  writer. 

Smith  claims  all  power  polishers  are  injurious  in 
prophylaxis  work.  R.  G.  Hutchinson,  Jr.,  says,  "Rotary 
brush  wheels  on  the  engine  are  an  abomination  and  do 
infinitely  more  harm  than  good  when  brought  in  contact 
with  the  soft  tissues,  but  soft  rubber  discs  and  cups,  if 
kept  wet  and  not  rotated  very  rapidly  or  pressed  too 
hard,  may  be  used  to  advantage. ' ' 

INSTRUMENTS  FOR  HAND  POLISHING  IN   PEOPHYLAXIS. 

There  are  a  great  many  ^^orte  polishers  on  the  market 
which  are  herewith  illustrated.    Dr.  Harrell.  of  Gaines- 


150 


Peactical  Okal  Prophylaxis. 


■ 


I<^ia.  19.    The  Bkst  Forms  of  Hand  Polishers  for  Prophylaxis 

Work. 


Matekiax,s  Used  ix  Peophylaxis.  151 

ville,  Texas,  invented  the  best  instrument  ever  produced 
for  the  purpose  of  prophylaxis  treatment.  The  sale  of 
this  prophylactic  polisher  is  now  controlled  by  the 
Oxylene  Company  of  San  Antonio,  Texas. 

In  the  porte  polisher  various  kinds  of  points  can  be 
used.  Generally,  however,  they  are  made  of  orange-wood, 
and  shaped  out  into  a  point  or  into  a  wedge.  In  addition  to 
the  porte  polisher,  it  is  well  to  have  about  a  dozen  large 
size  orange-wood  sticks  sharpened  into  various  shapes 
for  immediate  use.  The  broad  points  to  be  used  on  the 
broad  sides,  and  the  small  ones'  for  use  between  the  teeth 
and  in  the  fissures. 

A  new  point  must  be  placed  in  the  porte  polisher  for 
every  patient,  for  as  soon  as  the  patients  begin  to  learn 
something  about  prophylaxis,  and  the  treatment  ^and 
technique,  they  are  very  particular  and  watch  very  care- 
fully to  see  that  everything  is  as  aseptic  as  it  should  be. 
If  the  sticks  of  orange-wood  or  bass-wood  be  used,  the 
wood  should  be  washed  carefully,  a  new  point  cut,  and 
the  sticks  kept  in  a  glass  jar  filled  with  antiseptic  solu- 
tion. Before  I  began  doing  this,  I  frequently  had  the 
patients'  ask  me  if  I  used  the  same  stick  on  all  of  the 
patients. 

Dr.  H.  A.  Kelley  suggests  the  use  of  strips  of  shoe 
peg  wood  Avhich  can  be  cut  off  the  exact  width  required. 
He  claims  that  these  have  the  advantage  of  orange-wood 
sticks  in  that  thej^  give  an  expansive  flat  surface  for 
polishing  the  flat  surfaces  of  the  teeth,  and  that  the^^  are 
much  superior  to  the  regular  orange-wood  sticks.  They 
can  be  procured  very  cheaply  at  any  shoe  factory  or 
wholesale  shoe  shop.  Dr.  F.  H.  Skinner  furnishes,  with 
his  instruments,  a  box  of  prepared  orange-wood  points 
which  are  excellent.  The  S.  S.  White  Dental  Manufactur- 
ing Co.,  and  the  J.  W.  Ivory  Company,  make  a  specially 
shaped  point,  for  use  in  porte  polishers,  which  is  quite 
an  advantage  in  some  places'.  The  greatest  aid  as  a  sub- 
stitute for  the  orange-wood  stick  is  the  contribution  of 


152 


Peactioal,  Okal  Prophylaxis. 


Dr.  J.  W.  Jungman,  of  Cleveland,  whicli  consists  of  round 
bass-wood  sticks  about  six  inches  long  wMcb  are  placed 
in  a  1  in  1000  solution  of  bichloride  with  green  soap. 
They  remain  in  this  until  thoroughly  saturated.  Dr. 
Jungnaan  furnishes  me  with  the  following  prescriptions 
for  use  with  these  bass-wood  points. 


d^/X^i^i^  OL^^ftry 


Fig.   20. 


No.  1 
Prescribe  in  cases  of  pyorrhoea 
where  the  enamel  will  permit  the 
use  of  a  gritty  powder, 

Pulv.  Castile  Soap Parts  % 

Zinc.   Sulpho   Garb "       1 

Pulv.  Pumice   (Fine) ...     ''       6 
Oxide  Tin,   (Mercks) ...     "       3 

Creata  Preseip    "     12 

Flavor,  Q.  S. 


No.  2 
Where  it  Avill  not  permit  a  gritty 
powder. 

Pulv.  Castile  Soap Parts  % 

Saceh.  Alba.  Pulv "       1 

Oxide  Tin,    (Mercks)  ..."       4 

Zinc.    Sulpho   Carb "      1 

Creata    Preeip "     12 

Flavor,  Q.  S. 


No.  3 
In    well-kept    mouths   Avhere    no 
medicament  is  required. 

Pulv.  Castile  Soap Parts  % 

Saeeh.  Alba  Pulv "      1 

Oxide  Tin,   (Mercks) ..."       3 

Creata  Preeip    "     12 

Flavor,  Q.  S. 


No.  4 
In  acid  mouths. 

Pulv.  Castile  Soap Parts  % 

Sacch.  Alba  Pulv "       1 

Oxide  Tin,   (Mercks)    .  .     "'       3 
Sodium  Borate  (Sqnibbs)   "       2 

Creata  Preeip "     12 

Flavor,  Q.  S. 


I  secure  large  mouthed  bottles,  such  as  those  used  for 
barbers'  pomade,  which  hold  about  one  half  pint.  Into 
these  I  put  the  various  mixtures  which  I  use  in  prophy- 
laxis work. 

In  beginning  this' work,  we  must  be  cautious  not  to  use 
the  common  pumice  stone,  as  it  will  cause  cupping  in  at 
the  cervical  margin  of  the  teeth.    From  the  use  of  this 


Materials  Used  iist  Peophylaxis.  153 

heavy  abrasive,  I  have  noticed  cups  in  the  teeth  of  a 
numher  of  patients.  After  the  patients  have  been  on  the 
treatment  for  several  months,  it  is  not  necessary  to  have 
this  abrasive  used  every  time.  The  finer  mixtures  of 
oxide  of  tin  or  prepared  chalk,  or  the  preparations  made 
by  Dr.  Carmichael  (called  Carmi-Lustro)  may  be  used. 
The  views  of  Dr.  Carmichael  on  the  subject  of  the 
abrasive  for  use  in  prophylaxis  are  so  interesting  that  I' 
feel  it  best  to  give  his  views  in  his  own  language : 

"The  polish  or  gloss  of  enamel  was  put  there  by 
nature  to  protect  the  teeth  from  diseases.  If  this  liighly 
glossed  surface  of  the  tooth  enamel  was  retained,  foreign 
matter  could  not  readily  adhere  and  if  the  surfaces  were 
always  polished  to  the  gum  margin,  the  teeth  would  not 
decay,  nor  would  there  be  dental  pyorrhoea. 

''All  the  substances  in  general  use  for  cleaning  teeth 
are  harsh  and  gritty ;  though  they  be  very  fine  grit,  they 
accomplish  the  purpose  only  by  a  scouring  process,  thus 
gradually  destroying  the  natural  gloss  of  the  enamel. 
Although  these  scratches  are  not  visible  to  the  naked  eye, 
they  are  sufficient  to  destroy  the  brilliancy,  and  leave 
the  surface  all  the  more  susceptible  to  receive  foreign 
adliesions ;  in  other  words',  the  more  we  scour  the  teeth, 
the  more  we  must  scour,  to  keep  them  clean;  to  say  noth- 
ing of  destroying  the  life  luster;  as  proof  of  this,  it  is 
only  necessary  to  dry  the  teeth  to  disclose  the  fact  that 
the  enamel  gloss  has  been  dulled. 

''It  may  be  necessary,  nevertheless,  for  the  dentist  to 
apply  a  very  finely  powdered  abrasive,  to  remove  stains 
in  cleaning  teeth,  and  this  should  not  be  used  over  the 
entire  surface  of  the  teeth,  but  confined  to  the  stained 
area,  using  a  preparation  of  a  character  that  will  not 
scratch. 

"Experience  has  proven  that  a  friction  dry  rub  is 
not  only  more  effective  in  removing  the  adhesions,  but  the 
life  luster  becomes  more  intensified. 

"The  enamel  must  be  kept  so  brilliant  that  the  teeth 


154  Peactical  Oeal  Pkophylaxis. 

will  ward  off  disease.  To  accomplisli  this,  we  must  adopt 
those  measures  that  will  restore  the  teeth  to  a  state  of 
nature,  which  is  in  line  with  the  highest  attainment  in 
dentistry. ' ' 

In  the  use  of  any  polishing  instrument  bear  in  mind 
the  curvature  of  the  teeth,  and  do  not  rub  in  one  place,  up 
and  down,  but  follow  the  curvature  of  the  teeth  in  a 
circular  motion,  and  at  a  slow  rate  of  speed.  In  this 
manner,  we  are  enabled  to  feel  any  accumulation  which 
we  wish  to  remove.  If  the  point  slips  over  the  tooth  as 
though  it  were  greased,  we  know  that  it  is  enveloped  in  a 
secretion  which  must  be  removed.  We  must  educate  our 
fingers  up  to  this  delicate  sense  of  feeling.  We  soon  learn 
that  a  regular  patient's  teeth  feel  entirely  different  from 
one  who  has  not  had  this  care.  There  is  a  peculiar 
squeeh  of  the  patient's  teeth,  and  the  minute  we  hear  this, 
we  have  caught  on  to  the  proper  manner  of  handling  our 
porte  polisher.  Just  at  the  free  margin  of  the  gums  it 
must  be  polished  very  carefully.  Many  operators, 
through  too  rapid  movement  of  the  porte  polisher  or 
through  fear  of  injuring  the  gums,  lose  much  of  the  im- 
portance of  this  work.  I  have  not  found  the  contact  of 
the  porte  polisher  against  the  gums  to  be  injurious,  if 
rightly  used. 


CHAPTEE     XIV. 

PEOPHYLAXIS  TREATMENT  OF  FISSURES  AND 

GROOVES. 

SOFT    SPOTS, SENSITIVE    AEEA   TEEATMENT. 

As  previously  mentioned,  the  fissures,  grooves,  and 
pits  in  tlie  teeth  will  cause  us  the  greatest  amount  of 
trouble.  The  first  time  that  this  condition  occurs  in  the 
mouth  is  following  the  eruption  of  the  first  lower  molar. 
It  has  been  my  practice  for  years  to  attend  to  these  teeth 
as  soon  as  they  appear  through  the  gums,  whether  the 
patient  is  on  prophylaxis  or  not,  but  certainly  if  on 
proj)hylaxis.  The  tooth  should  first  have  the  sulci  cleaned 
out  with  a  fine  pointed  instrument.  The  surface  of  the 
tooth  is  then  cleaned  off  with  some  mild  abrasive.  The 
tooth  is  kept  as  dry  as  possible,  and  then  sterilized  with 
absolute  alcohol.  When  this  is  done,  the  whole  erupted 
surface  of  the  tooth  is  covered  with  some  quick  setting- 
cement.  Many  prefer  one  of  the  copper  cements,  but  I 
have  never  seen  any  advantage  in  it.  The  erupting  per- 
manent (tooth  being  behind  the  temporary  molars,  at  a 
lower  level,  furnishes  a  depression  which  forms  an  ideal 
catch  basin  for  decaying  foods.  Again,  if  the  children 
brash  their  teeth,  which  they  seldom  do  at  this  age,  it 
is  doubtful  whether  they  ever  clean  this*  surface.  As  the 
tooth  grows  up  into  place,  the  attrition  of  food  soon 
wears  all  the  cement  away  except  that  portion  in  the 
grooves.  As  soon  as  the  tooth  is  brought  into  use  for 
mastication,  if  this  cement  has  not  been  worn  away,  it 
can  be  removed,  and  in  many  cases  we  mil  find  that  no 
further  attention  is  necessary.  However,  if  deep  sulci 
have  developed,  we  can,  with  a  real  small  burr,  cut  the 
fissue  just  sufficient  for  a  small  gold  filling,  or,  perhaps, 
the  little  groove  can  be  filled  with  cement.  It  will  be  sur- 
prising to  note  how  this  will  last  in  this  small  line  cavity. 


156  Peactical  Oral  Peophylaxis. 


Fig.  21.    Fissure  in  Lower  Bicuspid   (Solbrig). 

Such  a  tooth,  unless  properly  treated,  is  almost  sure  to  develop  a 

serious  decay  in  the  fissure. 

Sometimes  the  simple  opening  and  bevelling  of  the 
walls  that  lead  to  the  sulci  so  that  the  tooth  brnsh  can  be 
gotten  down  into  it,  is  all  that  is  necessary.  The  grooves 
in  the  buccal  surfaces  of  the  teeth  had  best  be  ground  out 
^\T.th  the  smallest  stone  possible,  and  then  the  surface 
thoroughly  polished.  However,  if  the  groove  is  of  such 
depth  that  the  grinding  will  go  through  the  enamel,  or, 
as  is'  often  the  case,  a  small  pit  shows  somewhere  along 
this  groove  it  can  be  filled  with  a  cement  filling  as  this  is 
probably  the  best  to  put  in  this  position. 

SOFT  SPOTS. 

Soft  spots  at  the  juncture  of  the  teeth  and  the  enamel 
margin  where  previous  recession  of  the  gums  has  taken 
place,  have  proved  one  of  the  most  disappointing  o^Dera- 
tions  in  prophylaxis',  and  yet  I  feel  that  the  percentage 
of  successful  work  along  this  line  is  sufficient  to  warrant 
me  in  giving  the  technique;  it  is  certainly  worth  while 
trying  this  method,  even  if  the  tooth  should  require  a  fill- 
ing some  years  later. 

Small  white  spots  in  childrens'  teeth  can  be  polished 
away.  The  method  of  doing  so  is  by  taking  the  smallest 
size  mounted  stone,  grinding  down  to  hard  surface  and 


Sensitive  Spots  on  Teeth.  157 

then  applying  cuttle  fish  discs,  and  finally  polishing  off 
with  an  old  fashioned  moose  hide  polishing  point  or  with 
Darby's  Hard  Buff  Polisher  No.  3,  used  in  the  dental  en- 
gine. On  this  polisher  should  be  used  oxide  of  tin  or 
some  preparation  such  as,  "  Carmi-Lustro, "  provided  the 
decay  or  white  decalsification  does  not  extend  through  the 
depth  of  the  enamel.  However,  more  extensive  decays  just 
over  the  juncture  of  the  cementum  and  the  enamel  on 
the  tooth  root  often  presents  a  leathery  surface  which  is 
very  difficult  to  handle  with  this  protective  technique. 

The  surfaces  in  the  anterior  part  of  the  mouth  might 
be  handled  with  stich  substances  as  nitrate  of  silver 
hereafter  described  but,  this  being  a  question  of  position, 
the  next  best  thing  is  to  try  the  polishing  technique.  If 
this  leathery  condition  does  not  extend  into  the  inter- 
spaces, we  sometimes  get  excellent  results  by  the  simple 
removal  of  this  condition,  and  polishing  the  surface  as 
just  described  after  removing  this  leathery  substance. 
If  we  find  a  cavity,  now  is  the  time  to  fill  it.  However, 
if  we  reach  sound  tissue,  we  should  have  a  cup-shaped 
surface.  This  surface  can  be  maintained  in  a  polished 
condition  and  it  may  not  require  filling  for  many  years. 
Many  times'  in  attempting  to  operate  at  this  point,  we 
find  an  extra  sensitiveness,  and  the  patients  will  some- 
times say  that  they  would  rather  have  the  tooth  extracted 
than  to  have  you  polish  at  this  spot.  Then  is  the  time  to 
use  the  procedure  given  me  many  years  ago  by  Dt. 
Taylor,  of  Hartford,  who  sprinkled  a  small  amount  of 
powdered  cocaine  over  the  gum  margin  allowing  the 
moisture  to  dissolve  the  crystals.  He  advises  that  the 
cocaine  be  used  in  about  the  same  manner  as  when  apply- 
ing the  rubber  dam,  but  cautions  the  operator  not  to 
allow  the  patient  to  swallow  it.  Dr.  Taylor  used  this 
method  for  many  years  without  the  slightest  symptom  of 
trouble. 

One  other  point,  wliich  can  be  used  in  the  treatment 
of  these  sensitive  spots  at  the  gum  border,  especially  after 


158  Peactical  Oeal  Peophylaxis. 

tliey  have  been  cleaned  out,  polished,  and  are  still  sensi- 
tive, is  the  application  of  a  small  burnisher. 

The  patient's  head  is  held  firmly,  and  the  hand  hold- 
ing the  burnisher  is  held  against  the  tooth  which  is  to 
be  treated.  G-reat  pressure  is  applied  with  up  and  down 
motion,  being  careful  not  to  let  the  instrument  wound  the 
gum  margin.  This  burnishing  should  be  kept  ujd  for 
several  seconds.  It  is  remarkable  what  relief  this  method 
sometimes  affords,  a  considerable  length  of  time  elapsing 
before  the  return  of  the  sensitiveness.  I  can  give  no 
better  explanation  of  this  than  the  answer  given  by  the 
student  who  said  that  this  burnishing  ''brads  the  nerve 
terminals  at  this  point."  There  are  undoubtedly  irri- 
tated and  exposed  nerve  ends,  and  the  patient  will  tell 
you  so  when  you  attempt  to  do  the  operating.  The  suc- 
cessful *'br adding"  in  my  own  mouth  on  an  upper 
bicuspid,  where  there  has  been  a  slight  recession  of  the 
gums,  has'  afforded  me  the  greatest  relief  of  any  pro- 
cedure which  has  been  suggested  or  tried. 

In  the  case  of  small  mouths,  I  use  one  of  the  various 
cheek  distenders,  which  not  only  enables  the  operator  to 
work  with  greater  ease,  but  also  much  to  the  comfort  of 
the  patient. 


CHAPTER     XV. 
RESULTS  OF  PROPHYLAXIS  TREATMENT. 

The  various  arg-uments  lorouglit  forward  against  the 
monthly  system  of  prophylaxis  will  not  have  any  weight 
with  anyone  who  has  observed  a  patient  who  has  been 
upon  this  system  for  a  while.  Six  months  treatment  will 
change  the  whole  appearance  of  the  ordinary  month, 

1st,  The  mucous  membrane  will  assume  a  normal  pink 
color,  not  only  around  the  buccal  surfaces  of  the  upper 
teeth  but  in  every  part  of  the  mouth. 

2d,  Teeth  that  disfigure  the  face  can  be  improved  in 
appearance,  for,  if  their  surfaces  be  brought  to  a  high 
state  of  polish,  and  the  surrounding  tissues  healthy,  one 
does  not  notice  so  much  their  ill  shape. 

3d,  Many  defects  in  the  teeth  can  be  worked  out, 
white  spots'  removed,  and  grooves  smoothed  out. 

4th,  Hypersensitiveness  of  the  cervical  margin  and 
irregularity  of  the  nerves  can  be  corrected. 

5th,  Decay  is  prevented. 

6th,  The  vital  structures  within  the  tooth,  and  those 
surrounding  it,  especially  the  peridental  membrane,  are 
maintained  in  normal  condition. 

7th,  The  mouth  is  safeguarded  against  violent  infec- 
tions. 

8th,  Osseous  structures  are  protected  from  the  irrita- 
tion oT  deposits  or  infection. 

9th,  Pyorrhea  is  positively  prevented. 

10th,  Last,  but  not  least,  the  greatest  result  in  prophy- 
laxis is  the  aid,  training,  and  maintenance,  by  the  patient 
at  home,  of  a  perfect  dental  toilet  technique. 

If  it  were  always  possible  to  place  the  mouth  in  a  per- 
fectly clean  condition  as  to  caries  and  fissures,  and  the 
patient  carried  out  the  instructions  for  care  of  the  teeth 
at  home,  we  would  be  able  to  demonstrate  in  every  case 


160  Pkactical  Oral  Prophylaxis. 

that  "Clean  teeth  never  decay."  Unfortunately  this  is 
seldom  the  case,  and  we  are  often  humiliated  in  our 
prophylaxis  by  the  discovery  of  a  whiteness  showing- 
through  the  enamel,  giving  evidence  of  the  carious  con- 
dition underneath. 

It  is'  well  to  explain  to  the  patients,  before  placing 
them  on  prophylaxis,  in  regard  to  the  claim  that  prophy- 
laxis prevents  decay,  that  some  slight  carious  condition 
may  possibly  develop  during  the  first  six  months  or  year ; 
that  in  the  interproximal  surfaces,  between  the  molars 
and  incisors,  the  etching  of  the  enamel  may  have  pro- 
ceeded so  far  that  it  will  be  impossible  to  prevent  further 
decay.  It  is  not  always  possible  to  find  these  at  once  as 
they  sometimes  do  not  develop  for  six  months  or  a  year 
after  the  patient  has  been  placed  on  prophylaxis. 

In  my  experience  of  about  ten  years  in  prophylaxis, 
I  do  not  recall,  in  any  of  these  reg-ular  patients,  a  decay 
beginning  out  in  the  open,  that  is;  on  a  surface  where  it 
was  |30ssible  to  maintain  a  polished  surface.  Many  teeth 
with  deep  sulci  and  grooves  may  decay  in  spite  of  all  the 
prophylaxis  you  can  give  them,  because  it  is  impossible 
for  the  dentist  or  the  patient  to  keep  these  depressions 
in  a  perfectly  clean  state.  It  is  the  best  policy  to  fill  these 
-either  jDcrmanently  or  temporarily  as  explained  in  the 
chapter  on  technique  of  prophylaxis. 

In  regard  to  the  prevention  of  pyorrhea,  I  can  say 
that  in  my  own  experience  not  one  has  shown  the  least 
tendency  to  this  disease.  Others'  who  are  doing  this 
same  work  have  observed  the  same  thing,  of  course,  this 
is  not  taking  into  consideration  the  patients  who  have  had 
pyorrhea  at  the  time  they  began  prophylaxis. 

As  evidence  for  my  own  satisfaction  of  the  fact  that 
prophylaxis  really  does'  prevent  disease,  I  selected  pages 
at  random  from  my  records,  which  give  the  amount  of 
dental  work  required  by  patients  in  the  five  years  before 
they  began  Prophylaxis  in  comparison  with  the  amount 
of  work  they  have  had  done  since.    I  included  in  these 


Results  of  Peophylaxis  Treatment.  161 

statistics  such,  restorative  work  as  fillings'  and  abscesses. 
For  the  sake  of  comparison  with  this,  another  table  was 
made  of  dental  work  done  for  patients  of  about  the  same 
class  and  mouth  conditions  as  the  patients'  who  have 
been  on  prophylaxis. 

These  tables  show  that  the  patients  who  have  been  on 
prophylaxis  have  had  little  or  no  dental  work  done  since 
entering  upon  this  system.  The  second  table  suggests, 
that,  had  these  first  named  patients  not  entered  upon  a 
system  of  prophylaxis,  their  dental  requirements  w^ould 
have  been  like  those  named  in  table  No.  2,  with,  their 
constantly  recurring  dental  bills.  In  addition  to  this,  all 
these  prophylaxis  iDatients  report  fewer  doctor  bills',  and 
their  illness,  if  any,  has  been  light  in  character;  also  they 
have  derived  much  pleasure  from  the  knowledge  that 
their  mouths  were  in  a  healthy  and  beautifully  polished 
state.  Of  as  much  interest  as  all  the  above  results  is'  the 
pleasure  derived  by  the  operator  who  sees  the  accumula- 
tive effects  of  his  work,  bringing  imkept  mouths  to  a 
healthy  state.  I  have  seen  prophylaxis  patients  so  that  you 
could  tell  them  across  the  room,  when  they  smile,  by  tke 
brilliancy  of  tlieir  teeth.    Also  the  satisfaction  of  having 

people  say,  "TVTiy,  she  must  be  a  patient  of  Dr. , 

for  her  teeth  are  so  clean  looking  and  pretty." 

The  gums  of  a  patient  on  prophylaxis  should  become 
hard  and  pink,  and  should  hug  the  teeth  closely.  In  other 
words,  show  a  condition  of  perfect  health.  The  fillings, 
which,  ordinarily  would  show  rough  margins'  and  surfaces, 
should  present  the  appearance  of  having  just  been  inser- 
ted ;  and,  after  the  patient  has  been  on  the  treatment  long 
enough,  all  surfaces  should  exhibit  a  luster  which  reflects 
the  lio'ht. 


CHAPTER     XVI. 

SOME  IMPORTANT   OBSERVATIONS   ON   THE 

TEETH  AND  SALIVA. 

TOOTH   ENAMEL, 

Pickerill,  and  others,  who  have  studied  the  histology 
of  human  teeth,  have  shown  that  the  enamel,  as  laid 
down  in  the  formation  of  the  tooth,  may  contain  defects, 
as  well  as  fissures,  and  unclosed  rug£e.  This,  of  course, 
favors  decay  by  the  retention  of  carbo-hydrates  in  the 
form  of  food  stuifs,  with  the  final  development  of  micro- 
organisms. If  we  examine  any  mouth  which  is  subject  to 
a  large  number  of  caries,  we  will  find  that  the  enamel 
contains  some  break  on  its  surface,  which  defect,  while 
small,  is  sufficient  to  retain  food  and  allow  it  to  decom- 
pose. 

Dr.  Head  is  authority  for  the  statement  that  the 
enamel  of  the  teeth,  which  has  become  decalcified  in  weak 
solution  of  lactic  acid,  or  orange  juice,  even  to  the  point 
of  losing  their  opacity,  will  be  quite  restored  when  sub- 
sequently immersed  in  saliva  for  some  time.  While  this 
seems  rather  hard  for  us  to  accept  at  first,  thorough 
chemical  investigation  seems  to  bear  out  this  experiment 
and  gives  us  a  clue  on  which  to  build  our  future  prophy- 
lactic technique,  and  mouth  wash  formulas.  There  is  no 
doubt  that  the  enamel  of  the  teeth  varies  in  structure, 
hardness,  density,  permeability,  and  solubility,  and  that 
we  must  recognize  the  fact  that  a  large  part  of  this  de- 
parture from  the  normal  must  be  due  to  developmental 
as  well  as  acquired  defects.  Taking  this  view  of  the  mat- 
ter, our  prophylaxis  treatment  must  be  directed  towards 
the  enamel  in  its  formative  period  in  order  that  the 
proper  osmosis  of  the  lime  salts  and  phosphates  shall 
take  place. 


Impoetaxt  Obsekvatioxs  ox  Teeth  axd  S.\liva.    163 

Eose,  Bunge,  Malcolm,  and  Pickerill  have  made  ex- 
haustive experiments  in  an  effort  to  determine  whether 
or  not  the  enamel  of  the  teeth  could  be  influenced  by  the 
drinking  of  water  heavy  with  magnesium  or  calcium 
salts.  The  result  was  that  the  structure  of  the  teeth  was 
not  influenced  to  such  an  extent  as'  are  the  other  bones  of 
the  body.  Their  conclusions  were,  that  the  hardness  of 
the  water  was  not  naturally  or  essentially  a  factor  for  us 
to  consider. 

ox  saliva. 

Saliva  in  the  normal  mouth  varies  in  character  from 
a  thin  watery  nature,  copiously  discharged,  to  a  thick, 
ropy,  tenacious  nature  such  as  we  often  see  in  unclean 
mouths. 

Some  writers  have  endeavored  to  show  that  the 
lessening  of  the  quantity  of  the  saliva  is  responsible  for 
an  excessive  amount  of  dental  caries.  So  far  as  I  have 
been  able  to  observe  clinically,  the  question  of  quantity 
is  not  of  so  much  importance.  Recently,  I  was  baffled  in 
the  case  of  a  young  married  woman,  who,  when  excited 
or  nervous,  suffered  from  temporary  stenosis  of  all  the 
salivary  ducts,  so  that  the  mouth  was  almost  as  dry  as 
though  she  had  been  taking  atropin.  So  great  was  the 
pain  sometimes  caused  from  this  condition  that  the 
patient  became  very  despondent.  As  the  mouth  and  the 
surrounding  structures  were  in  a  perfectly  normal  state, 
I,  and  my  medical  associates,  were  at  first  unable  to  find 
any  indications  for  treatment  or  to  afford  the  patient 
any  relief.  We  began  to  treat  her  for  a  trouble  far 
removed,  and  one  which  at  first  we  thought  had  no  con- 
nection with  the  condition  of  the  mouth,  for  we  supposed 
that  getting  her  mind  off  her  mouth  conditions  would  at 
least  give  her  some  degree  of  comfort.  She  improved  for 
a  time  under  a  physician's  care  but  later  passed  out  of 
our  observation.  The  point,  however,  is  that  while  the 
patient's'  mouth  was  dry,  she  did  not  exhibit  any  con- 
siderable amount  of  carious  action  of  the  teeth. 


164  Pkactical,  Oral  Prophylaxis. 

It  lias  generally  been  noticed  that  where  a  pyorrheal 
condition  is  present,  we  have  an  increased  supply  of 
saliva,  yet  there  is  often  noted  a  total  absence  of  caries. 
In  the  mouth  of  the  case  described,  there  was  a  reduced 
amount  of  saliva,  yet  the  mouth  showed  only  a  small 
amount  of  care.  My  observation,  while  based  upon  a 
large  number  of  cases,  does  not  allow  me  to  say  with  any 
positive  degree  of  certainty,  that  caries  are  influenced  by 
quantity  of  saliva,  still  I  am  of  the  opinion  that  the  pres- 
ence of  some  element  in  the  saliva,  as  well  as  the  quantity 
of  the  solution,  must  be  loked  for  as  the  prohibitive  agent. 

Of  course,  we  must  realize  that  stagnation  of  any 
secretion  must  result  in  decomposition  or  putrefaction, 
and  that  this  will  contain  some  degree  of  infection,  but  I 
am  forced  to  believe  that  it  does  not  have  as  much  in- 
fluence as  Pickerill  would  have  us  think. 

It  is  a  strange  law  of  nature  that  the  quantity  of  the 
saliva  is'  not  increased  by  the  drinking  of  ordinary 
liquids.  You  can  have  the  patient  with  thick,  ropy  saliva 
drink  large  quantities  of  water  without  perceptibly  in- 
fluencing this  condition.  However,  stimulants  do  produce 
vasomotor  effects  either  as  a  stimulant  or  al  depressant. 
Tea  is  given  as  the  greatest  depressant,  while  acid  fer- 
mented liquor,  as  port  wine,  produce  the  highest  alkal- 
inity index. 

The  conclusion  which  I  wish  to  lead  up  to  is  this.  It 
does  not  matter  what  the  condition  of  the  saliva  is,  nor 
the  quantity,  nor  the  quality.  What  we  are  most  interes- 
ted in  is  to  note,  that  the  patient  with  an  abnormalty  of 
the  saliva  has  a  much  better  chance  for  a  return  to  the 
normal  or  the  physiological  condition  when  on  regular 
prophylaxis. 

Pickerill  has  made  considerable  study  of  the  com- 
position and  behavior  of  the  human  saliva,  and  from  his 
writings  we  have  the  following  deductions.  On  the 
degree  of  excitability  of  the  various  glands  which  furnish 
the  saliva,  he  has  found  that  the  ordinary  tasting  of 


Obseevations  OiSr  Sai^iva.  165 

foods  does  not  excite  the  glands  to  action  and  that 
"bread  and  butter  depress  the  secretion."  In  his  table 
of  experiments  from  bread  and  butter  at  1.73  alkalinity 
per  minute,  he  runs  the  list  of  pine-apple,  cake,  grapes, 
celery,  meat,  stewed  apples  and  up  to  lemon  juice  which 
is  6.24:.  Also,  it  is  shown  that  the  alkalinity  of  the  parotid 
saliva  is  greater  than  that  of  the  other  glands,  although 
these  glands  furnish  such  a  small  quantity  of  secretion. 
It  is  a  most  beautiful  and  wonderful  provision  of  nature 
that,  whatever  the  degree  of  acidity  in  the  food  products, 
the  proper  alkalinity  is  furnished  by  the  saliva,  although 
the  acid  food  may  be  so  strong  that  it  could  etch  the 
enamel  surface  of  the  teeth,  as  in  the  case  of  the  Siles- 
ians,  who  suck  lemons  for  a  pastime.  The  after  flow  con- 
tains sufficient  alkalinity  to  neutralize  the  acid,  and  the 
question  of  alkalinit}^  is  one  of  the  most  important  with 
which  we  have  to  deal. 

PTYALIN. 

Physiologists  teach  us  that  the  action  of  ptyalin  in  the 
saliva  is  for  the  purpose  of  converting  the  starch  into 
sugar,  in  order  that  the  sticky  or  solid  material  might  be 
changed  into  one  soluble  and  ready  for  absorption.  We 
are  led  to  believe  that  ptyalin  has  more  to  do  with  mouth 
conditions  than  this. 

The  operation  of  extirpation  of  most  of  the  salivary 
glands  has  not  resulted  in  any  difference  in  undigested 
starch  products.  In  order  to  prove  this,  Pickerill  selected 
two  rabbits',  A  and  B.  One  was  kept  as  a  control  while 
the  other  one  had  the  parotid  and  submaxillary  glands  on 
both  sides  removed.  Weeks  after  the  operation  feces 
were  collected  at  intervals,  and  the  examination  showecf 
no  difference  or  a  very  small  difference  of  undigested 
starch.  Pickerill  suggests  that  the  function  of  iDtyalin 
is  not  as  heretofore  supposed,  but  rather,  for  acting  upon 
the  carbohydrates  remaining,  or  debris  left  around  the 
teeth,  to  be  used  after  the  process  of  digestion  in  the 
intestines  has  gone  on. 


lG(j  Peactical  Oeal  Prophylaxis. 

SULPHO- CYANIDE  OP  POTASSIUM. 

Another  substance  in  the  saliva  which  has  been  the 
subject  for  much  speculation  is  sulpho-cyanide  of  potas- 
sium. Some  thought  that  by  its  quantity  increasing  we 
would  gain  some  protection  against  caries,  and  yet,  El- 
lenberger  and  others  have  demonstrated  that  this  sub- 
stance is  not  found  in  many  animals  which  are  immune 
to  caries.  Some  authors,  as  Neuchael,  Lowe,  Beech,  and 
Greyger,  are  of  the  opinion  that  some  salt  of  this  sub- 
stance, administered  internally,  might  in  some  way  pro- 
duce an  inhibitory  action  on  dental  caries.  However, 
Miller  and  Kirk  have  exactly  the  opposite  opinion.  About 
all  we  know  is  that  a  weak  solution  of  sulphur-cyanide  of 
potassium  possesses  slight  antiseptic  qualities.  Experi- 
ments show  that  the  percentage  of  this  drug  in  the  saliva 
can  be  increased  by  the  internal  administration  of  one 
fourth  of  a  grain  daily,  and  the  suggestion  is  given  to  try 
this  in  those  cases  where  children's  teeth  are  being  de- 
stroyed by  caries.  It  is  doubtful  whether  any  direct  good 
will  result  but  it  appears  to  be  worth  giving  a  trial. 

PHOSPHATES  AND   CHLORIDES. 

Phosphates  and  chlorides  undoubtedly  increase  our 
desire  for  a  certain  class  of  food  and  drink.  For  instance, 
if  we  rinse  our  mouths  with  a  mild  solution  of  S'odium 
chloride  we  are  enabled  the  more  readily  to  taste  sweets. 

MUCIN.' 

This  substance,  so  far,  seems  to  have  only  the  function 
of  a  lubricant  or  protective  covering  for  the  mucus  mem- 
brane. Unfortunately,  it  is  also  precipitated  around  the 
teeth  and,  instead  of  being  a  protection,  forms  various 
kinds'  of  plaques.  Into  this  precipitation  is  caught  the 
food  products  which  in  time  cause  the  development  of 
caries. 


Observations  on  S.ajliva.  167 

possible  presence  op  immune  bodies  in  the  saliva, 

Miller  suggests  that  phagocytes  or  protective  bodies 
may  be  present  in  the  blood.  However,  the  presence  of 
phagocytosis  has  not  yet  been  established.  If  this  is  ever 
done,  it  is  possible  that  opsomins  of  the  saliva  and  the 
raising  of  this  index  will  become  just  as  potent  a  factor 
in  dental  jDrophjdaxis  as  it  has  proven  in  raising  the  im- 
munity of  certain  diseases. 

The  result  of  all  this  investigation  gives  us  very  little 
knowledge  which  we  can  use  in  our  work  of  preventing 
decay.  This  much  we  do  know,  that  organic  acids  in- 
crease the  alkalinity  of  the  glands,  and,  conversely,  netual 
salts  produce  diminution  of  the  protective  substances 
which  we  wish,  and  that  if  we  remove  oral  sepsis,  by  a 
system  of  prophylaxis,  the  saliva  can  be  made  one  of  the 
greatest  aids  in  keeping  the  teeth  clean,  because,  in  a 
proper  condition,  it  acts  by  constantly  washing  the  teeth 
and  surrounding  parts,  giving  the  patient  the  most  ideal 
mouth  wash,  nature's  own  make,  which  formula  has  not 
iDeen  equalled  by  anyone. 


CHAPTEE     XVII. 

METHODS  OF  NOTIFICATION  AS  USED  BY 
KELLS,  FONES,  AND  ADAIE. 

Since  the  whole  idea  of  prophylaxis'  is  founded  on 
regidarity  and  system,  it  is  well  to  work  out  for  each 
individual  some  scheme  to  carry  this  out.  Dr. 
Smith  simply  telephones  his  patients  once  a  month.  Dr. 
Kells,  of  New  Orleans,  has  a  list  upon  which  he  places 
the  names  of  all  patients,  at  their  request  for  regular 
attention.  At  stated  intervals  from  this  list  he  mails 
cards  as  jyer  the  illustration: 


Dr.  Kells  Would  Remind 


M. 


that  the  time  has  now  arrived  when,  to  insure 

their  best  care,   teeth  should  be 

examined. 

1237  Maison  Blanche. 
Phone  Main  1617. 


Fi(,.    J^. 

Dr.  Kells'  idea  is  that  he  wants  the  patients  to  know 
that  he  is  interested  in  them,  but  does  not  wish  to  place 
himself  in  a  position  of  commanding  them  to  come  to  Ms 
office,  as  it  might  be  embarassing  sometimes'  to  call  a 
patient  who  had  decided  to  go  to  some  other  dentist.  The 
recipient  of  this  card  is  not  commanded  to  come  to  him, 
but  is  just  reminded  that  his  teeth  need  some  attention 
and  he  may  go  where  he  pleases  for  this  work. 


Methods  of  Notification-.  169 

Dr.  A.  C.  Fones  mails  the  patient  an  engagement  card 
when  he  thinks  it  time  for  his  teeth  to  have  a  treatment. 
In  order  that  he  may  know  whether  the  patient  has 
received  this  notice  or  not,  he  encloses  with  the  engage- 
ment card  a  self  addressed,  stamped  envelope,  which 
contains  a  second  card  bearing  the  same  date  as  the 
notice,  which  is  to  be  signed  and  returned  by  the  patient. 


Dr.  Alfred  C.  Foxes: 

Your    appointment    card    for 
June  3d,  at  3  P.  M. 
has   been    received    and    accepted. 
Signed 


Fig.   23. 

If  the  patient  had  to  telephone  his  acceptance  or 
write  a  note,  Dr.  Fones  might  not  be  sure  as  to  a  definite 
engagement.  By  this  system  he  makes  it  so  easy  that  the 
patient  readily  signs  the  return  card,  and  mails  it  in  the 
envelope  already  addressed  to  Dr.  Fones. 

Others  doing  prophylaxis,  simply  leave  it  to  the 
patients  to  come  in  at  regular  intervals'.  None  of  these 
plans  seemed  to  fit  my  ideas  of  carrying  out  this  work  so 
I  devised  the  following  scheme : 

At  first,  I  designated  certain  hours  throughout  each 

day  for  this  special  work.    Mrs. 's  appointment 

was  on  the  10th,  and  she  was  reminded  the  day  previous. 
So  on  down  the  list.  This  scattered  the  work  all  through 
the  month  and  interfered  with  regular  dental  operations. 
The  next  plan  was  to  bunch  all  this  work  into  whole  days, 
and  the  organization  of  what  I  call  my  ''Prophylaxis 
Class."  Certain  days  in  each  month  were  devoted  ex- 
clusively to  this  work  and  set  aside  accordingly.  For  in- 
stance, the  second  Tuesday,  Wednesday,  and  Thursday  in 


170  Peactical  Oeal  Pkophylaxis. 

each  montli.  Afterwards  I  added  other  days  as  new  pa- 
tients accumnlated. 

The  book  used  was  like  an  ordinary  dental  engage- 
ment book,  only  the  engagements  were  permanent,  and 
the  book  had  only  eight  or  ten  pages,  each  page  rep- 
resenting a  day.  By  referring  to  the  cut  of  the  engage- 
ment book,  you  will  see  that  we  knew  Mrs.  Smith  had  a 
permanent  engagement.  Her  time  was  paid  for  whether 
she  came  or  not.  By  adhering  closely  to  these  engage- 
ments' of  one  half  hour  each,  we  found  that  we  could  treat 
from  twelve  to  fifteen  patients  in  each  of  these  days.  Now 
having  a  list  like  this  of  several  days,  it  was  out  of  the 
question  to  phone  all  of  these  patients  every  month  so  I 
had  printed  the  card  of  notification  which  is  mailed  the 
day  previous  to  the  time  for  treatment. 

A  large  number  of  patients  to  treat,  and  this  work 
exclusive  for  the  day,  make  it  very  interesting,  both  to 
myself  and  the  patients.  These  cards  are  neatly  printed 
and  only  the  dates  have  to  be  filled  in  by  the  secretary. 


8 :30— MRS.  WM.  SMITH 

419  Piedmont  Avenue 
'Phone  490 

9  :00— MR.  FRANK  JONE'S 

43  Peachtree  Street 
'Phone  8960 

10:00— MISS  RUBY  SIMPSON 

76  Johnson  Avenue 
'Phone  2442 

Second  Monday  in  Each  Month 


Part  of  Page  from  "Permanent  Engagement  Book.-" 
Prophylaxis  Engagements  for  the  Second  Monday  in  Each  Month. 

¥i(i.    24. 


Methods  of  Notification. 


171 


The  da}^  before  his  first  engagement  he  receives   a 
postal  card  with  his  dates,  thus : 


SECOND  MONDAY  IN  EACH  MONTH 


DATES  rOR  PROPHYLAXIS  TREATMENT 


PRESERVE  THIS  CARD 

January   Monday  10,  at 

February    

March    

April    

May    

June     

July    

August  

September  

October    

November    

December     


10, 

at  9 

o'clock 

14 

u 

11 

14 

a 

li 

11 

li 

it 

9 
13 

it 
it 

11 

li 

it 

8 

11 

ti 

12 

li 

li 

10 

It 

it 

7 

a 

It 

12 

li 

It 

Charge  $- 


per  year. 

A  reminder  card  will  be  mailed  previous  to  each  date  but 
failure  to  receive  such  notice  does  not  entitle  patient  to  another 
engagement  in  the  same  month  without  extra  charge,  unless  failure 
to  be  present  is  due  to  unavoidable  cause,  in  which  event  notice 
must  be  given  several  hours  in  advance. 

The  charge  for  prophylaxis  is  by  the  year  for  twelve  regular 
engagements,  and  is  payable  semi-annually  in  advance.  If  for 
any  cause  these  treatments  be  discontinued  before  the  expiration 

of  contracted  time  a  charge  of  $ will  be  made  for  each  date 

nip  to  the  time  notice  is  received  to  discontinue. 

Appointments  are  not  to  be  changed  more  than  three  times  per 
year. 


Fig.   25. 


172  Practical  Oral  Prophylaxis. 

For  each  succeeding  engagement  lie  gets  a  postal  card 
very  similar,  like  this : 


rOUR  ENGAGEMENT   FOR   PROPHYLAXIS   IS 

AT O'CLOCK 

The  charge  for  this  treatment  is  by  the  year  from  date  of  first 

engagement  and  is  payable  in  advance.    The  date  and  honr  is 

fixed,  if  possible,  to  conform  to  convenience  of  patient 

and  is  not  to  be  changed  oftener  than  twice  a  year 

As  this  time  is  reser\'ed,  failure  to  meet  engagement  results  in  loss 

to  patient  and  can  not  be  made  up   unless  the  absence  is 

caused  by  Providential  hindrance,  in  which  event  notice 

must  be  given  a  dav  in  advance 


Fig.   26. 

The  patients  shonld  not  commence  our  system  of 
prophylaxis  unless  they  mean  to  stay  at  least  a  year ;  we 
enter  the  charge  in  our  ledger  for  one  year,  and  a  bill  is 
rendered  them  for  one  half,  or  the  whole  of  the  amount. 
This  must  be  paid  in  advance  if  this  time  is  to  be  saved 
for  them. 

At  the  first  appointment,  on  the  record  ledger  sheet, 
we  make  a  note  of  all  cavities',  including  the  incipient 
ones,  and  all  defects  of  the  mouth.  The  jDatient  should  be 
made  acquainted  with  all  these  conditions  and  shown  the 
note  in  the  dental  ledger.  At  the  first  treatment  the 
patient  must  invest  in  two  brushes,  floss  silk,  and  dentri- 
fice  cream,  and  he  is  taught  how  to  use  them.  One  brush 
has  the  name  of  the  patient  engraved  on  the  handle  with 
a  dental  bur  and  made  plain  Avith  a  smear  of  ink.  This 
is  kept  in  the  office  in  the  formaldehyde  sterilizer  to  l)e 
used  solely  for  teaching  the  patient  to  care  for  his  teetli. 
TJie  patient,  at  first,  does  not  understand  all  this  busi- 


Methods  of  Notification.  173 

ness  of  cards  and  dates  but  the  system  keeps  up  his  inter- 
est. After  the  third  visit  the  benefit  is  apparent,  and  the 
patient  is  yours  to  command.  After  years  of  study  and 
practice  this  system  has  been  evolved  as  the  most  efficient 
method  of  handlina^  the  work. 


CHAPTER     XVIII. 

XoTincATioisr  op  Patients. — Recoed  of  Cases. 

By  John  Oppie  McCall,  D.  D.  S. 
Notification  .  System.    By  Heney  A.  Kelley,  D.  M.  D. 
Notification  of  Patients. — Technique  op  Peophytoaxis 
Tkeatment.     By  Gillette  Hayden,  D.  D.  S. 


notification  of  patients. EECOED  OF  CASES. 

BY  DE.    JOHN   OPPIE    m'CALL^   BUFFALO,    N.   Y. 

''These  two  subjects  are  considered  in  one  chapter, 
because  the  two  things  can  be  very  readily  and  advantage- 
ously combined.  This'  is  done  by  having  the  record  chart 
printed  on  a  6x4  card  which  is  kept  in  a  card  index  system, 
and  which  thus  serves  as  the  basis  of  the  follow-up  cam- 
paign, so  necessary  to  secure  the  best  results  in  this' 
field. 

''We  will  consider  notification  and  follow  up  first.  The 
back  of  the  record  chart  shown  below  may  be  ruled  in 
several  ways  according  to  individual  ideas.  The  main 
thing  is  to  have  columns  for  date  of  appointment,  length 
of  time  consumed,  and  remarks'.  The  writer  does  not 
keep  the  financial  account  on  this  card,  and  for  several 
reasons.  The  card  is  to  be  laid  on  the  bracket  table  while 
patient  is  in  the  chair.  It  thus  serves  as  a  record  of  past 
appointments  with  their  possible  history  of  delinquency 
on  the  part  of  the  patient,  as'  well  as  a  ready  reference 
to  the  pathological  conditions  in  the  mouth.  A  financial 
statement  forms  no  integral  part  of  such  a  reference  card 
and  is  not  one  of  the  things  of  which  we  want  to  remind 
the  patient,  at  least  while  in  the  chair.  Appointments  for 
the  next  sitting  may  be  noted  on  these  cards  in  the 
presence  of  the  patient,  and  then  be  checked  off  when 
kept. 

"The  filing  of  these  cards  is  not  alphabetical,  but  hj 
months   (or  by  days  of  the  month,  if  so  desired).     An 


Methods  of  NoTiPiCATiOiSr.  175 

appointment  having  been  kept,  the  card  is  filed  in  the 
month  or  day  of  the  month  when  the  patient  is  next  to  be 
given  treatment.  As  the  end  of  the  month  is  reached,  the 
month  index  card  is  moved  to  the  back  of  the  file,  thus 
bringing  forward  the  cards  of  those  to  be  seen  the  fol- 
lowing month,  who  will  then  be  notified  of  the  impending 
visit.  Patients'  cards  are  only  moved  back  in  the  file 
after  the  treatment.  Hence  at  the  end  of  the  month  the 
cards  of  those  patients  who  have  failed  to  keep  their 
appointments'  for  any  reason  will  be  found  at  the  front  of 
the  index,  and  will  remain  there  until  properly  dis- 
posed of. 

"The  method  of  notification  of  the  patient  will  depend 
partly  on  the  patient,  but  the  initiative  in  making  ap- 
pointments can  seldom  be  left  to  the  patient  if  good  re- 
sults are  to  be  had.  A  notification  and  appointment  card 
sent  by  mail  is  usually  the  best  method,  although  with 
many  patients  the  telephone  accomplishes  the  same  end 
with  less  friction.  The  patient  should  be  given  to  under- 
stand at  the  time  the  case  is  started  that  the  dentist  pro- 
poses to  send  an  appointment.  If  this  procedure  does  not 
meet  the  approval  of  the  patient,  the  matter  can  be  talked 
over  at  the  time  and  the  need  of  such  action  explained, 
thus  settling  the  method  of  notification  to  be  followed  for 
that  patient,  and  avoiding  possible  disagreeable  incidents 
later  on.  The  following  is  the  text  of  the  card  used  by 
the  writer. 


Dr.  John  Oppie  McCall  begs  to  suggest  the  advisability 
of  making  an  appointment  for  a  prophylactic  treatment.  Experi- 
ence has  shown  that  short  sittings  at  regTilar  intei-\'als  are  neces- 
sary, that  the  improvement  secured  by  previous  treatment  may 
not  be  lost.  Your  ease  having  been  imdertaken,  responsibility 
for  its  success  dictates  this  reminder. 
Time  has  been  reserved  for  vou  at o'clock 


Fig.   27. 


Iv6  Peactical  Oral  Prophylaxis. 

'^With  this  is  also  enclosed  a  regular  appointment 
card,  which  can  be  tucked  in  purse  or  pocket  to  refresh 
the  patient's  memory. 

' '  The  method  of  recording  pathological  conditions  has 
been  developed  on  the  basis  of  the  needs  of  the  general 
practitioner,  but  can  be  used  quite  as'  readily  in  a  practice 
devoted  to  this  field. 

"The  system  was  suggested  by  Dr.  A.  D.  Black,  but 
has  been  considerably  modified  by  the  writer.  The  un- 
derlying idea  is  to  have  a  key  of  numbers  or  letters,  which 
through  their  various  combinations  may  serve  to  indi- 
cate and  diagnose  various  pathological  conditions. 

' '  The  chart  shown  here  is  printed  on  a  5x3  card,  but  a 
larger  one  may  be  used,  if  desired,  with  correspondingly 
larger  chart.  The  diagnoses  are  recorded  on  it  in  the 
spaces  indicating  the  location  of  the  conditions  recorded, 
by  means  of  three  letters  which  tell  the  tissue  affected, 
the  cause  of  the  trouble,  and  the  result  shown  at  the  time 
the  examination  is  made.  The  three  letters  refer  to  the 
three  columns  of  the  key,  the  first  letter  referring  to  the 
first  column,  the  second  letter  to  the  second  column,  etc. 

' '  The  key  letters  take  up  very  little  room,  yet  make  as 
complete  a  record  as  one  written  in  longhand.  The  key 
is  readily  memorized  and  hence  records  are  instantly 
available.  The  reduction  of  records  to  a  key  system  has 
another  advantage ;  namely,  that  it  is  not  known  to  the 
patient,  and  the  dentist  is  thus'  spared  the  necessity  of 
explaining  the  edges  of  fillings  and  crowns,  etc.,  for  which 
some  colleague  is  responsible,  and  which  may  have  caused 
some  trouble. 


Methods  of  Notification, 


177 


KEY   TO   DIAGNOSIS   OF   PULPAL   AND   PERIDENTAL  LESIONS. 


Pathological 
Couditiou  in 

A.  Pulp 

B.  Gum  Margin 
(J.  Pericementum 


Cause 

A.  Caries 

B.  Lack  of  insulation 

C.  Traumatic  injuiy 

D.  Denudation  of  root 

E.  Abrasion 

F.  Salivary  calculus 

G.  Serumal  calculus 
H.  Lack    of    contact 

of    teeth,    fillings, 

etc. 
J.    Improper    contact 

of    teeth,    fillings, 

etc. 
K.  Mal-occlusion 

(other  than  above) 
L.  Improper    margin 

of  filling  or  crown 
M.  Improper  restora- 
tion    of     occlusal 

surface 
y.  Mouth  hygiene 
0.  Systemic     disturb- 

banee 


Result 

A.  Active  hyperemia 

B.  Passive  hyperemia 

C.  Tubular  calcification 

D.  Secondan'  dentine 

E.  Pulp   stones 

F.  Hypertrophy 

G.  Stasis 
H.  Infection 

J.  Putrescence  (pulp 

canal) 
K.  Pericementitis 
L.  Abscess  (incipient) 
M.  Abscess  (^rith  sinus) 
iST.  Recession 
0.  Denudation  without 

recession 
P.  PyoiThea 
R.  Looseness 
S.  Elongation 
T.  Bone   absorption 

without  denudation 
U.  Sensation 


•'Thus  ABD  indicate  a  pathological  condition  of  the 
pnlp,  due  to  a  filling  without  proper  thermal  insulation, 
resulting  in  formation  of  secondary  dentine.  BFX  indi- 
cates a  lesion  of  the  giim  margin  due  to  salivary  calculus, 
resulting  in  recession.  CKP  indicates  a  peridental  affec- 
tion caused  by  mal-occlusion  resulting  in  pyorrhea.  This 
key  can  be  made  to  serve  for  quite  a  complex  diagnosis, 
as  for  instance  in  the  case  of  pulpal  hyperemia  due  to 
denudation  of  a  root  in  the  course  of  a  progressing  pyor- 
rheal  affection.  The  diagnosis  of  the  pyorrhea!  condition 
Tvill  be  noted  as  above,  and  the  pulp  trouble  will  be  re- 
corded thus  A.PB.  the  period  indicating  that  the  last  two 
letters  are  taken  from  the  last  column,  the  one  indicat- 
ing cause  of  course  preceding  the  other.     In  case  two 


178 


Pkactical  Oeal  Prophylaxis. 


causes  are  found,  as  is  not  uncommon,  the  letters  will  be 
included  between  two  iDeriods,  as  C. JN.A.  This  indicates 
a  peridental  disorder  due  to  improper  contact  of  teeth 
and  improper  care  by  the  patient,  resulting  in  hyperemie 
condition. 


M. 


R 

L 

m 

s 

[6] 

[5] 

s 

m 

m 

m 

ai 

a 

m 

SI 

m 

[H 

a 

® 

E 

E 

B 

E 

m 

E 

m 

51 

a. 

E 

m 

m 

E 

E 

m 

E) 

RE^ 

ARK 

S: 

Fig.  2S.     Chart  B.    McCall. 


' '  On  the  chart,  the  teeth  are  indicated  by  numbers  for 
the  ujDper,  and  letters  for  the  lower,  the  same  number  or 
letter  indicating  the  corresponding  tooth  on  either  side 
of  the  median  line.  The  right  upper  cuspid  is  3E,  the  left 
lower  first  molar  is  FL.  Again  the  key  is  readily  memor- 
ized, and  is  the  most  compact  way  of  designating  the 
teeth  in  recording  various  operations.  The  chart  shows 
a  series  of  square  and  oblong  spaces  which  represent  the 
hard  and  soft  tissues.  The  left-hand  teeth  are  found  at 
the  right  of  the  mediam  line  on  the  chart,  this  being 
their  position  in  the  mouth  when  the  operator  faces  the 
patient,  and  vice  versa.  The  little  squares  containing 
the  number  or  letter  represent  the  occlusal  or  incisive 
surfaces  and  are  surrounded  by  a  space  representing  the 
buccal,  mesial,  lingual  and  distal  surfaces  of  the  teeth. 
In  this  space  are  recorded  diagnoses  of  pulp  troubles^, 


Methods  of  Notificatiox. 


179 


and  also  erosion,  cavities,  etc.,  of  which  a  permanent 
record  is  to  be  kept.  It  is  not  intended  for  a  record  of 
operations  performed.  The  horizontal  oblong  space  at 
the  top  of  the  diagram  represents  the  labial  gum  tissue, 
and  notations  in  regard  to  that  tissue  or  the  correspond- 
ing peridental  membrane  are  placed  in  it.  The  vertical 
horizontal  spaces  under  it  represent  the  mesial  and  dis- 
tal soft  tissues,  and  the  horizontal  oblong  just  above  the 
heavy  center  line  indicates  the  lingual  gum  tissue.  The 
position  of  these  spaces  are  reversed  for  the  lower  teeth. 
See  section  of  chart  enlarged  below:" 


-   -       (^-e-^JilA^^ 


Fin.   29. 


NOTIFICATION  SYSTEM  OF  HENEY  A.  KELLET,  D.  M,  D., 
POKTLAND,   MAINE. 

''My  system  of  notification  is  very  simple.  We  will 
consider  that  a  patient  presents  himself  for  work  and 
we  wish  to  get  him  on  to  the  system  of  prophylaxis.  [ 
give  him  a  talk  along  the  lines  of  preventive  dentistry 
and  explain  the  theory  of  prophylaxis.  Having  obtained 
his  permission  to  put  him  on  this  system  I  give  him  a 
treatment  and  dismiss  him,  ha\dng  first  inquired  as  to 
what  days  of  the  week  are  best  for  him  for  appointments 


180  Peactical  Oeal  Prophylaxis. 

and  what  hour  in  the  day  is  preferred.  I  tell  him  I  will 
notify  him  when  I  want  to  see  him  again.  After  he  has 
gone,  my  secretary  first  enters  him  upon  the  list  of  my 
patients  who  are  on  the  prophylactic  treatment.  I  tell 
her  how  long  a  time  I  want  to  elapse  before  he  has 
another  treatment  and  she  turns  to  my  appointment  book 
and  enters  his  name  as  near  that  time  as  she  can,  con- 
sidering his  wishes  as  to  day  of  week  and  hour.  Then  a 
few  days,  say  a  short  week,  before  the  time  of  his  ap- 
pointment my  secretary  calls  him  up  by  telephone  and 
says,  'Tou  desired  Dr.  Kelley  to  send  you  an  appoint- 
ment for  your  prophylactic  treatment  about  this  time. 
Now  Dr.  Kelley  has  reserved  the  time  on  such  a  day  and 
such  an  hour  for  you.  Will  this  day  and  hour  be  agree- 
able to  you.'  If  he  says  yes,  the  appointment  slip  is 
mailed  to  him.  This  must  be  done  to  avoid  the  un- 
certainty of  the  telephone  and  to  impress  him  with  the 
importance  of  the  appointment.  Should  the  time  re- 
served prove  to  be  one  not  possible  to  him,  some  other 
appointment  for  prophylaxis  made  for  some  other 
patient,  not  yet  notified,  can  be  offered  and  his  time  ex- 
changed with  that  jDatient.  This  is  done,  of  course,  as 
the  secretary  telephones.  You  will  readily  see  with  many 
prophylactic  patients  on  your  book  you  have  great  lati- 
tude this  way. 

''This  is  all  there  is  to  the  system,  except,  if  you  have 
to  rely  upon  the  mail  alone,  you  must  have  some  system 
in  which  you  get  a  return  answer  to  your  appointment 
when  first  sent,  to  know  that  your  patient  receives  the 
appointment  and  to  prevent  loss  of  time  owing  to 
failure  of  patient  to  receive  your  appointment  when  sent. 
It  is  impossible  to  fix  the  blame  for  this  kind  of  a  slip-up 
and  you  have  to  assume  the  loss.  One  thing  you  have  to 
be  careful  about,  is  that  you  do  not  in  some  way  break 
this  system.  Any  system  is  defective  in  that  you  may 
think  it  is  working  when  it  is  not.  So  once  in  a  while  it 
is  well  for  your  secretary  to  check  up  the  patients  that 


Methods  of  Xotificatiox.  181 

are  on  the  list  of  those  having  the  prophylactic  treatment 
and  see  that  they  are  all  on  the  appointment  hook  some- 
ivJiere. 

"I  believe  that  the  dentist  should  always  look  out  for 
the  patient  and  should  send  for  him  when  he  thinks  he 
should  make  a  dental  call  and  it  should  not  be  left  to  the 
patient  to  decide  when  he  will  call  upon  the  dentist.  This 
system  of  notification  for  prophylaxis  gives  you  the 
means  of  educating  your  patients  along  this  idea." 

SYSTEM    USED    AXD    DESCRIBED    BY    DE.    GIT;LETTE    HAYDEX,    OF 
COLUMBUS,  OHIO. 

'^ Notification  of  Patients. — The  name,  address,  and 
telephone  number  of  a  patient  beginning  the  regular 
monthly  treatment  are  placed  on  a  card,  and  the  card, 
after  having  the  date  of  the  first  treatment  entered  on 
it,  is  placed  in  the  file  box  one  month  in  advance  of  the 
date  of  the  first  treatment.  For  example:  The  patient 
has  the  first  treatment  January  3d.  The  notification  card 
has  this  date  entered  on  it,  and  is  then  placed  in  the  file 
box  back  of  the  month  card  of  February  and  date  card  of 
3.  On  January  31st  or  February  1st  the  assistant  takes 
all  cards  bearing  date  of  February  3rd,  calls  each  patient 
by  telephone,  and  arranges  the  hour  for  the  appointment. 

''In  every  case  this  has  proven  the  most  satisfactory 
of  all  methods  tried.  The  patients  find  it  easy  to  arrange 
hours  which  do  not  conflict  with  other  appointments 
which  they  must  make,  and  I  find  less  disturbance  from 
appointments  cancelled  or  changed  to  other  dates.  An- 
other feature  of  this  method  is  that  the  appointment  book 
will  have  only  two  or  three  days  in  advance  filled  com- 
pletely. This  permits  of  opportunities  to  supply  time 
not  too  far  removed,  to  out  of  town  cases,  to  emergency 
and  other  cases. 

' '  Out  of  town  patients  are  notified  by  mail  a  week  in 
advance  that  they  are  due  on  such  date,  and  that  an 
hour  (usually  that  given  on  the  card  as  the  most  con- 


182 


Practical,  Oeal  Prophylaxis. 


T'enient  for  tliem)  is  reserved  for  them  on  two  different 
-days.    They  make  the  selection  of  the  day  in  the  reply. 

^^  Charges. — Charges  are  made  for  each  treatment. 
To  those  having  an  account,  statements  are  mailed  every 
six  months. 

''Technique  of  Prophylaxis  Treatment. — In  the  usual 
cases  presented  each  month  for  treatment  the  buccal, 
lingual  and  liabial  surfaces  of  the  teeth  are  reached  with 
S.  S.  W.  Scaler  No.  3,  or  6  and  7  (from  set  of  eight).  The 
mesial  and  distil  surfaces  are  reached  with  Smith  files 
Nos.  13  and  14,  or  Townes  Files  33  and  34,  or  35  and  36, 
or  with  Nos.  1  to  8  of  the  Bates'  Scalers,  according  to  the 
size  of  the  inter-proximal  space  and  the  extent  of  the 
recession  of  the  tissues. 


Fig.  30.     Bales'  Scalers,  Ivory. 


"The  teeth  are  then  stained,  a  few  at  a  time,  with  a 
disclosing  solution  containing  4  dr.  each  of  water  and 
glycerine,  15  gr.  potassium  iodide,  15  gr.  zinc  iodide,  5 
gr.  iodide  crystals.  For  applying  this  solution  cotton  is 
wound  around  a  wooden  tooth  pick. 

"At  present  the  Carmichael  preparations  are  being 
used  with  satisfaction  as  abrasive  and  polisher.  The 
cleansing  powder  is  carried  to  the  tooth  to  be  polished  on 


Methods  of  Notification^.  183 

a  Tvedge-shapecl  orange-wood  stick  dipped  first  in  phenol- 
sodique.  A  straight  large  sized  orange  wood  stick  is  used 
where  the  surfaces  of  the  teeth  are  accessible  to  it.  A 
wedge  shaped  point  carried  in  the  right  angle  porte 
polisher  is  necessarily  used  on  all  surfaces  not  reached 
by  the  straight  stick.  Wherever  the  loss  of  the  tissues 
permits  the  use  of  a  small  wood  point  on  the  approximal 
surfaces,  these  portions  of  the  teeth  are  polished  in  the 
same  manner  as  the  other  surfaces. 

''Ribbon  floss,  X  size,  charged  with  the  abrasive  then 
passed  between  the  contact  points  and  carried  up  just 
under  the  free  margin  of  the  gum  and  with  a  sliding  mo- 
tion of  the  fingers  carrying  the  floss  the  aiDproximal  sur- 
faces are  polished.  With  an  aseptic  dental  najDhin 
wrapped  about  the  index  finger  and  charged  with  fine 
polishing  material,  the  final  polish  is  given  to  the  teeth, 
and  a  light  massage  to  the  gums. 

''A  spray  containing  a  zinc  chloride  solution  is  used 
to  complete  the  treatment. 

"Sticks  are  prepared  by  first  sharpening  them  to  a 
wedge  shape  on  a  very  small  plane  set  (plane  side  up)  in 
a  vise,  then  rounding  the  corners  and  smoothing  off  with 
sand  paper." 


CHAPTEE     XIX. 
TEAINING  OF  FEMALE  ASSISTANT. 

WHEjS^  should  such  help  be  installed  IlSr  A  DENTAL  OFFICE  f 
THE  BEST  WAY  TO  SECUEE  GOOD  HELP. METHODS  OP  OB- 
TAINING TELEPHONE  AND  RECEPTION  ROOM  RECORDS 
TO    BE    USED    BY    FEMALE    ASSISTANTS.— OFFICE 
TRAINING    FOR    THE    POSITION    OF 
DENTAL  NURSE. 

When  the  author  first  came  to  Atlanta,  some  fifteen 
years  ago,  there  was  only  one  white  female  assistant  in 
a  dental  office ;  several  dentists  had  negro  girls.  Shortly 
after  this,  some  of  the  dentists  began  putting  white  girls 
into  their  offices,  but  were  criticised  for  it.  Today,  such 
a  revolution  has  come  about  that  every  office  of  any 
reputation  has  from  one  to  three  young  ladies  employed. 
Even  the  term  '^ office  girl"  has  now  disappeared,  and 
each  young  lady  has  her  special  duties  to  perform,  and 
is  entitled  to  the  name  either  of  assistant  secretary,  book- 
keeper, or  dental  nurse. 

To  the  student  who  is  soon  to  start  a  practice,  to  the 
young  man  already  graduated,  or  to  the  older  practitioner 
who  has  not  availed  himself  of  this  great  help,  these 
pages,  I  hope  will  be  of  assistance. 

The  first  question  which  naturally  arises  when  the 
subject  is  brought  up  is,  "When  should  such  help  be 
installed!"  In  answer  to  this,  I  should  say  that  just 
as  soon  as  the  office  is  established,  and  the  patients 
begin  to  make  their  appearance,  then  should  the  train- 
ing of  the  assistant  begin.  In  other  words,  I  consider  the 
trained  female  assistant  just  as  necessary  to  the  dental 
office  as  the  chair  or  the  engine^ 

The  next  question  is,  "From  what  source  is  such  a 
girl  to  be  obtained  ?"    The  advice  that  I  give  my  students 


Training  of  Female  Assistant.  185 

in  a  rather  semi-serious  mood  is  that  they  insert  in  the 
daily  newspaper  exactly  the  description  of  the  girl  they 
desire,  withholding,  of  course,  their  own  name  and  ad- 
dress; the  office  will  probably  be  flooded  with  applica- 
tions. If  they  meet  these  pleasantly,  they  have  placed  an 
advertisement  in  just  so  many  homes  from  which  they 
may  receive  future  patronage. 

The  scheme,  however,  which  I  employ,  is  to  go  to 
the  floor-walker  in  some  department  store,  and  explain  to 
him  exactly  my  needs.  My  reason  for  this  is  that  in  his 
daily  watch  over  a  large  number  of  young  ladies,  of 
the  class  from  which  we  must  employ  the  ordinary  den- 
tal assistant,  he  has  the  chance  to  pick  out  the  one  to  suit 
the  position.  If  you  explain  to  him  that  it  is  a  regular 
position,  and  one  where  advancement  can  be  expected,  he 
will  frequently  tell  you  of  some  young  lady  in  his  em- 
ploy, with  whom,  for  the  sake  of  allowing  her  to  take  the 
better  position,  he  is  willing  to  dispense,  or,  if  he  is  not 
so  inclined,  he  will  generally  tell  you  of  some  one,  former- 
ly employed  by  him,  who  will  come  up  to  the  require- 
ments. I  have  always  found  the  girls  endorsed  by  the 
floor-walker  to  make  better  employees  than  those  secured 
from  other  sources.  I  have  also  found  that  applicants 
from  newspaper  ads  and  employment  bureaus  have  often 
not  been  able  to  furnish  the  proper  references. 

In  making  your  decision,  as  to  the  fitness  of  an  ap- 
plicant investigate  her  references.  If  she  can  give  the 
pastor  of  her  church,  you  may  generally  put  it  down  that 
this  counts.  Always  prefer  one  who  lives  at  home,  or 
with  her  relatives,  or  one  who  can  give  good  reasons  for 
not  living  at  home.  Give  the  preference  always  to  the 
older  applicant,  other  things  being  equal.  The  girl  under 
nineteen  years  of  age  has  no  place  in  the  dental  office. 

One  thing  that  must  be  guarded  against  is  the  good 
looking  girl.  In  my  own  experience,  as  well  as  that  of 
others,  I  find  that  such  a  girl  is  not  the  proper  applicant 
for  the  position  of  dental  assistant  or  nurse.     Not  that 


186  PEACTiCAii  Oeal  Prophylaxis. 

beauty  itself  is  a  detriment,  but  rather,  it  is  of  such  charm 
that  you  will  either  have  your  patients  talking  about  the 
good  looking  girl  in  your  office,  or  it  may  soon  lead  to  her 
taking  a  matrimonial  venture  and  your  assistant  is  lost 
to  you  as  soon  as  she  is  trained. 

Explain  to  the  applicant  that  it  will  take  several  years 
of  training  before  she  can  expect  any  consider.able  ad- 
vance of  wages.  From  the  very  first,  it  is  best  to  have 
this  understood.  I  have  noticed  that  the  dentist  who 
employs  a  young  lady  and  fails  to  have  this  understood 
at  first,  soon  finds  that  the  girl  is  trying  to  run  the  whole 
office.  He  has  made  so  many  promises  that  her  wages 
have  to  be  increased  before  the  dentist's  income  is  suffi- 
cient to  warrant  it. 

The  first  duty  of  the  female  assistant  to  the  dentist  is 
that  she,  being  a  good  house  keeper,  keep  his  office  in 
order.  This  must  be  understood  before  she  enters  the 
office  as  assistant.  No  matter  what  her  qualifications  are, 
if  she  is  not  willing  to  go  into  the  office,  and,  if  needs  be, 
scrub  the  blood  from  the  floor  after  an  operation,  she  is 
not  the  one  for  you.  She  must  be  willing  and  able  to 
keep  the  office  in  order  and  in  a  clean  state  for,  although 
our  buildings  have  janitors,  they  do  not  clean  the  cabinets 
and  wash  stands.  Many  times  she  will  be  called  on  to 
clean  the  basins  and  the  spittoons  after  a  bloody  opera- 
tion. 

The  young  lady  should  be  given  a  key  to  the  office, 
and,  at  least  half  an  hour  before  you  arrive,  should  open 
up  the  office,  dust  it,  and  turn  on  the  heat.  In  other 
words,  have  everything  ship-shape  on  your  arrival,  so 
that  without  further  delay  you  may  proceed  with  the 
patients. 

In  regard  to  her  dress,  I  would  advise  that  you  make 
some  distinction  or  dilference  from  the  ordinary  dress. 
Now  this  will  have  to  be  understood  at  the  time  she  takes 
the  position  for,  if  you  wait  several  months,  3^ou  will  find 
that  she  is  not  willing  to  change.    Many  girls  of  this  class 


Teaining  of  Female  Assistant.  187 

wear  gaudy  jewelry  and  gay  costumes.  You  will  have  to 
explain  to  them  that  they  are  in  the  same  position  as  the 
trained  nurse  and  must  wear  simple  clothing.  It  is  better 
that  she  wear  nurse's  costume  or  some  part  of  a  nurse's 
uniform. 

If  you  have  secured  the  services  of  the  proper  young 
lady,  and  you  cannot  secure  this  proper  applicant  on  a 
salary  of  less  than  $6.00  per  week,  this  amount  will  be 
well  spent,  and  she  can  save  the  dentist's  time,  and  time 
is  money  to  a  dentist.  In  addition  to  this,  she  is  in  a 
position  to  add  to  your  reputation,  because  she  will  talk 
your  business  better  than  you  can  yourself. 

As  the  majorit}^  of  dentists  do  not  employ  but  one 
young  lady,  I  will  describe  some  of  her  probable  duties 
which  she  will  have  to  perform  and  in  which  she  can  be  of 
real  worth  to  the  operator. 

It  will  be  best  not  to  try  to  teach  her  the  names  of  the 
instruments  the  first  week,  but  try  to  teach  her  the  use 
of  the  telephone.  I  would  suggest  that  the  dentist  himr 
self  not  answer  the  telephone  at  all.  Dr.  Kells,  for  ex- 
ample, will  not  answer  his  telephone  during  office  hours. 

There  is  a  good  reason  for  this.  These  telephone  mes- 
sages are  often  for  the  purpose  of  breaking  an  engage- 
ment, objecting  to  an  account,  or  complaining  about 
work.  In  making  engagements  over  the  phone,  you  are 
never  able  to  tell  just  how  much  time  to  leave  out  for 
such  and  such  an  operation.  It  is  much  better  for  the 
patient  to  come  to  the  office  for  an  examination.  This 
engagement  can  be  made  b}^  the  assistant. 

Dr.  Conrad  Deichmiller,  of  Los  Angeles,  has  a  tele- 
phone record  sheet  printed  and  padded.  The  sheets  are 
about  6x8  inches,  one  sheet  being  used  each  day.  He  has 
all  the  messages  that  have  come  in  or  gone  out  over  his 
telephone  accurately  recorded.  At  the  end  of  the  day  he 
sits  down  and  attends  to  each  one  at  his  leisure. 

When  the  assistant  makes    engagements,    I    would 
suggest  the  following  line  of  conversation: 


188  Pkactical  Oral  Prophylaxis. 

"Yes  this  is  No ■  Dr. 's  office. 

What  name,  please?  Yes,  he  is  here,  but  engaged  in  an 
operation.  It  will  be  a  favor  if  you  will  give  me  the 
message  as  I  make  engagements  for  him."  The  reason 
for  this  line  of  talk  is  that  it  impresses  the  patient  that 
you  are  busy. 

If  the  person  at  the  other  end  of  the  line  refuses  to 
give  the  message,  the  following  reply  should  be  made, 
''Leave  your  number  and  I  will  have  the  Doctor  call 
you  later."  If  the  message  is  delivered,  it  should  not  be 
delivered  to  you  verbally  but  written  on  a  slip  prepared 
for  phone  messages. 

This  gives  you  time,  also,  to  frame  the  proper  answer. 
If  an  engagement  is  to  be  made,  the  engagement  book  is 
taken  to  the  telephone.  If  a  bill  is  in  question,  you  may 
take  the  ledger  to  the  telephone  with  you. 

Have  it  distinctly  understood  that  your  telephone  is 
for  business,  and  not  for  the  young  lady  to  talk  to  her 
gentleman  friends,  for  some  day  while  such  a  flirting 
conversation  is  going  on,  a  patient  suffering  with  a  tooth- 
ache will  call  some  other  dentist,  not  being  willing  to  wait 
until  the  conversation  is  over. 

It  is  best  to  have  the  assistant  make  all  engagements 
which  must  be  recorded  in  an  engagement  book.  If  made 
over  the  telephone,  it  should  be  verified  immediately  by 
mailing  a  card  to  the  patient.  This  will  save  many  lost 
hours. 

She  can  make  all  bank  deposits.  She  should  be  instruc- 
ted how  to  write  a  receipt  and  to  receive  money  from 
patients  while  you  are  busy. 

She  must  be  instructed  how  to  handle  the  patients  in 
the  parlor,  especially  the  waiting  ones.  She  must  be  able 
to  explain  to  them  that  the  doctor  is  engaged  in  a  diffi- 
cult operation,  and,  in  justice  to  the  other  patient,  they 
must  wait  patiently.  There  is  one  thing  which  she  must 
not  talk  about,  and  that  is  what  is  going  on  in  tlie  operat- 
ing rooms.    She  must  be,  so  far  as  talking  to  the  patient 


Training  op  Female  Assistant.'  189 

on  tins  subject  is  concerned,  a  blank.  Especially  will  slie 
be  questioned  as  to  the  Doctor's  fees.  She  is  supposed 
to  Jiiwiv  nothing  along  this  line. 

As  I  have  said,  she  must  be  a  good  housekeeper.  It 
should  be  her  duty  to  see  that  the  janitor  sweeps  down 
the  walls,  that  the  mirrors  are  polished  each  morning, 
that  the  laundry  is  not  full  of  holes,  and  that  it  goes  out 
reg-ularl}^  and  comes  in  on  time.  She  should  have  the  pur- 
chasing^ of  the  towels,  napkins,  and  linen,  as  she  knows 
more  about  such  things  than  the  dentist.  One  of  the 
hardest  things,  I  find,  is  to  get  the  assistant  to  keep  an 
accnrate  laundry  list,  and  I  constantly  find  myself  buying 
a  new  supply  of  linen.  I  find  it  a  good  plan  to  buy  ordi- 
nary duplicate  order  books,  and  insist  that  the  quantity 
C)f  each  article  be  put  down,  and  that  a  duplicate  sheet 
be  put  with  the  clothes  ready  for  the  laundry,  then,  that 
this  slip  be  checked  before  receiving  the  clean  linen. 

If  she  is  to  be  of  value  in  assisting  around  the  chair, 
she  should  have  the  quality  of  seeing  ahead,  that  is,  of 
anticipating  the  needs  of  the  dentist.  In  other  words,  the 
dentist  should  not  have  to  tell  her  every  thing  to  be  done. 
The  minute  the  patient  sits  down,  she  should  put  a  pro- 
tecting napkin  around  his  neck,  and  place  a  cup  of  some 
antiseptic  mouth  wash  near  at  hand.  She  should  see  to 
it  that  the  chair  is  comfortable.  This  done,  she  should 
step  "a  side. 

I  have  found  it  better  not  to  keep  up  a  line  of  con- 
versation with  the  assistant.  If  a  code  of  signals  can  be 
arranged,  yon  will  find  it  to  an  advantage,  for,  sometimes, 
you  will  want  her  to  go  out,  and  to  tell  her  to  go  would 
defeat  your  purpose.  One  tap  of  the  insturment  could 
mean  for  her  to  stay,  two  for  her  to  retire. 

One  of  the  most  valuable  adjuncts  to  my  office  is  the 
use  of  a  card,  as  shown  below.  As  soon  as  patients 
arrive  they  are  furnished  this  card  by  my  female  assist- 
ant. She  sees  that  it  is  properly  filled  out  before  bring- 
ing it  to  operating  room  where  it  is  i^laced  in  a  special 


190 


Peactical  Oeal  Peoppiylaxis. 


holder  just  off  from  my  cabinet,  without  disturbing  me, 
yet  where  I  can  see,  the  full  significance  of  the  waiting 
caller  at  a  glance. 


Kindly  Weite  Name  and  Addeess  and 
Check  Youe  Call 

Name 

Address 

Wishes  to  see 

O  De.  Robin  Adaie 

0  For  Examination  [Fee  $1  to  $5] 

0  To  make  engagement 

0  Have  engagement 

0  Business  call 

0  Social  call 

Memorandum    


Fig.   31, 


This  enables  one  to  know  the  caller's  name  and  ad- 
dress, saves  introduction,  and  a  lot  of  questions.  If  the 
check  is  on  second  item,  then  the  assistant  makes  the  en- 
gagement without  disturbance.  I  have  never  yet  bad  a 
book  agent  check  anything  except  the  business  call,  and 
all  of  these  checks  are  requested  to  call  after  ofhee  hours. 
The  numbers  at  the  bottom  denote  the  number  of  patients 
waiting  before  the  last  ono  came  in.  This  card  enables 
the  assistant  to  handle  a  large  number  of  callers  without 
disturbing  the  dentist. 


The  Deisttal  Assistant.  191 

At  the  eucl  of  the  day  those  cards  are  taken  and 
all  work  done  for  each  is  figured  out.  I  have  their 
correct  address  which  may  be  new  since  my  last  work. 

Other  duties  for  a  female  assistant  are  suggested 
under  the  head  of  Dental  Nurse.  Many  of  these  can 
readily  be  taught  to  the  average  female  assistant. 

If,  perchance,  you  can  emj^loy  a  young  lady  who  is  a 
stenographer  and  book-keeper,  you  are  indeed  fortunate, 
for  there  is  nothing  more  needed  in  the  modern  dental 
office  equipment  than  careful  work  along  this  line.  While 
you  will  have  to  make  the  original  entries  of  work  done 
at  your  chair,  she  can  afterwards  record  them  in  the  den- 
tal ledger.  At  the  end  of  the  month,  she  can  save  you  a 
great  amount  of  time  by  making  out  the  statements. 

I  have  always  found  that  a  young  lady,  calling  up  a 
patient  for  a  delinquent  bill,  saying  that  she  is  book- 
keeper for  Dr. ,  and  that  it  is  time  for  closing 

up  the  books,  and  she,  iinding  that  the  bill  had  not  been 
paid,  would  like  to  send  around  for  it,  does  more  good 
than  putting  a  lawyer  after  them;. 

Some  dentists  have  their  bookkeeper  look  up  the  finan- 
cial rating  of  a  new  patient  when  he  first  presents  him- 
self, so  that  she  can  hand  the  dentist,  written  on  a  sheet 
of  paper,  just  what  to  expect  in  the  wa}^  of  payment. 
Even  the  information  given  by  the  city  or  telephone 
directory  is  most  valuable  at  this  time. 

OFFICE   TRAINING    FOR    THE    POSITION    OF    DENTAL    NURSE. 

If  the  dental  nurse  has  been  trained  up  from  the 
dental  assistant,  she  probably  knows  the  patients  and 
has  their  confidence  and  you  will  have  less  trouble  in 
introducing  this  line  of  work  into  your  practice.  It  is  to 
be  hoped  that  by  the  time  this  book  is  published,  some 
school  will  have  taken  advantage  of  this  opportunity  by 
])utting  into  its  curriculum  a  course  of  training  for 
dental  nurses.  As  the  question  will  be  taken  up  more 
fully  ill  tlio  latter  ]Kirt  of  the  chapter,  suffice  it  for  the 


192  Practical,  Oral  Prophylaxis. 

present,  to  give  some  suggestions  to  those  wlio  wisli  to 
train  their  own  assistant  for  prophylaxis.  Some  simple 
rules  may  be  of  help;  in  the  first  place,  it  will  not  be 
advisable  to  call  the  assistant  a  dental  nurse  until  she  has 
had  a  degree  of  training  and  has  become  somewhat  effi- 
cient. The  first  qualification  is  that  she  have  some  aim 
in  life,  and  be  of  settled  disposition,  for  the  girl  whose 
future  is  in  doubt  has  no  place  in  this  work. 

I  would  begin  the  training  by  placing  at  her  disposal 
some  of  the  simple  books  on  sterilization  as  given  for 
general  surgery. 

She  should  be  first  aid  in  minor  surgical  work,  and 
should  assist  the  dentist  in  administering  anesthetics.  In 
the  first  place,  it  is  an  absolute  necessity  that  a  female 
assistant  be  present  when  giving  an  anesthetic,  and  that 
she  be  taught  along  this  line,  for  many  is  the  time  that 
the  assistant  gets  stampeded  more  than  any  one  else.  I 
would  let  them  read  the  small  book  of  lectures  by  Dr.  de 
Ford.  In  this  way,  they  will  receive  the  knowledge  of 
what  is  expected  of  them  under  such  circumstances. 

The  anesthetic  having  been  determined  upon,  if  the 
patient  is  a  woman,  the  dentist  steps  from  the  room 
leaving  the  patient  in  the  hands  of  the  nurse.  The  nurse 
sees  that  the  corset  is  either  loose  or  removed,  the  tight 
collar  and  the  neck  band  opened.  The  dental  nurse  can 
at  this  stage  dispell  the  fear  from  the  mind  of  the  patient 
better  than  the  dentist.  She  should  put  around  the 
patient  the  protecting  apron  and  have  a  hand  spittoon 
within  reach  and  a  supply  of  towels  convenient.  She 
should  be  taught  how  to  proceed  in  the  case  of  an  acci- 
dent for,  if  she  is  not,  she  may  desert  you  at  a  critical 
moment. 


CHAPTER     XX. 
THE  DENTAL  NURSE. 

VIEWS   OF   FOISTES,    MEERITT,   HYATT,    HART,   EBEESOLE,   NODINE, 
KIRK  AND  SKINNER. THE  PROPOSED  LAW  FOR  MASSACHU- 
SETTS  AS   ENDORSED   BY  THE   STATE  DENTAL  SOCIETY. 

The  trend  of  the  times  is  toward  trained  dental  assis- 
tants for  oral  hygiene  work.  Women  now  employed  in 
this  occupation  have  been  designated  dental  nurses.  In 
many  offices  they  are  successful  in  the  field  of  prophy- 
laxis, in  the  schools:  they  are  doing  great  work  in  the  ex- 
amination of  children's  mouths,  and  in  the  various  clinics 
instituted  in  some  countries  they  have  proved  superior  to 
men  for  all  work. 

In  order  to  show  the  present  demand  for  dental 
nurses,  the  author  has  selected  from  the  published  views 
of  some  of  the  leading  men  in  our  profession,  quotations 
on  the  subject  which  are  given  at  some  length. 

Dr.  A.  C.  Fones,  says:  ''A  busy  practitioner  cannot 
comfortably  do  this  work  alone,  unless  he  limits  the  num- 
ber of  his  patients  to  comparatively  few.  He  must  have 
aid,  and  I  believe  the  ideal  assistant  for  this  work  to  be 
a  woman.  A  man  is  not  content  to  limit  himself  to  this 
one  specialty,  while  a  woman  is  willing  to  confine  her 
energy  and  skill  to  this  one  form  of  treatment.  A  woman 
is  apt  to  be  conscientious  and  painstaking  in  her  work. 
She  is  honest  and  reliable  and  in  this  one  form  of  prac- 
tice, I  think  she  is  better  fitted  for  the  position  of  prophy- 
lactic assistant  than  is  a  man." 

This  view  is  also  taken  by  Dr.  A.  H.  Merritt: 

"It  is  an  innovation  that  has  been  made  necessary 
by  the  evolution  of  dentistry.  It  is  in  the  line  of  pro- 
gress and  will  prevail.  It  may  not  come  this  year  or 
next,  but  that  is  of  little  consequence,  it  is  enough,  just 


194:  Peactical,  Oeal  Prophylaxis. 

now,  to  know  that  it  is  a  part  of  the  dentistry  of  the 
futnre.  Like  all  forward  movements  it  may  meet  with 
opposition,  and  that  from  those  most  directly  benefited, 
but  that  is  to  be  expected.  Progress  has  always  been 
made  in  the  face  of  opposition. 

"In  the  very  nature  of  things  it  must  go  forward,  and 
co-operating  with  it  to  the  end  that  the  public  shall  be 
better  served,  will  go  to  the  trained  dental  nurse." 

Dr.  T.  P.  Hyatt  takes  up  some  of  the  various  objec- 
tions which  have  been  raised  against  this  movement : 

"The  work  of  the  nurse  is  to  keep  all  the  exposed  sur- 
faces of  the  teeth  in  a  high  state  of  cleanliness  and  polish. 
Please  understand  that  when  I  say  polish  I  mean  the 
kind  that  is  secured  by  the  methods  advocated  by  Dr.  D. 
D.  Smith. 

"I  shall  make  no  attempt  to  show  the  need  of  dental 
nurses  in  our  dental  dispensaries  or  schools,  for  the 
reason  that  once  they  admit  their  need  in  our  offices,  it 
must  follow  that  the  need  is  great  and  greater  in  the 
dental  dispensaries  and  schools. 

"Up  to  the  present  I  have  only  heard  three  objections 
to  passing  laws  permitting  dental  nurses,  which  laws 
would  regulate  the  knowledge  required,  and  prescribe  the 
rules   and  regulations  under  which  they  should  work. 

"1st,  If  you  want  a  dental  nurse  take  a  graduate 
dentist. 

"2d,  If  this  work  is  so  important  is  should  only  be 
performed  by  a  college  graduate  holding  the  dental 
degree. 

"3d,  To  allow  any  one  other  than  a'  doctor  of  dental 
surgery  to  perform  any  service  in  the  month  is  to  lessen 
the  value  and  importance  of  our  work. 

"What  work  is  the  dental  nurse  expected  to  perform? 
To  fill  teeth?  To  make  crowns  or  bridges?  To  cut,  or 
remove  any  of  the  normal  structure,  such  as  tooth  struc- 
ture, gum  or  alveolus?  To  treat  pathological  conditions 
and  prescribe  drugs?    If  any  or  all  of  these  are  required 


The  Dental  Nuese.  195 

or  expected  of  the  dental  nurse,  tlieu  they  should  he 
graduated  doctors. 

''Those  advocating  dental  nurses  do  not  expect  any 
of  these  things. 

"Does  any  one  question  that  the  work  a  trained  dental 
nurse  does  is  important .'  The  health,  even  the  life  of 
the  patient  depends  upon  the  performance  of  these  duties 
regardless  of  who  does  them.  Tlieir  importance  being- 
admitted,  with  the  realization  that  the  success  of  an 
operation  depends  upon  their  being  done,  and  done  right, 
does  the  medical  profession  insist  that  only  graduated 
doctors,  or  women  who  have  secured  the  degree  of  M. 
D.  be  permitted  to  perform  these  important  services  ? 

"Another  objection  I  have  heard  and  with  due  re- 
spect to  those  who  make  it,  I  am  free  to  confess  my  sur- 
prise and  astonishment  that  any  one  for  a  moment  can 
believe  that  it  is  really  worth  considering  at  all.  The 
objection  is  this :  If  we  allow  young  women  to  become 
trained  dental  nurses,  a  great  many  might  start  dental 
offices  of  their  own.  It  seems  absurd  to  think  that  any- 
one could  advance  such  an  idea  with  any  seriousness: 

"Dental  nurses  will  be  of  such  inestimable  benefit  to 
the  public,  our  patients,  and  to  the  uplift  of  our  profes- 
sion, that  all  good  men  should  unite,  and  think  out,  and 
work  out  the  best  and  safest  plans  for  its  accomplish- 
ment. ' ' 

Dr.  Chas.  E.  Hart,  of  San  Francisco,  says  in  reference 
to  the  dental  nurse:  "I  have  two  with  me  at  present  and 
am  running  two  operating  rooms.  The  uniforms  that 
costume  the  nurses  are  made  of  white  material  and  of 
similar  substance  to  the  ordinary  surgical  gown,  and 
made  up  in  simple  form  with  pattern  to  suit  the  person." 

Dr.  TV.  G.  Ebersole,  of  Cleveland,  says:  "I  find  the 
lady  graduate  for  prophylaxis  work  to  be  very  satisfac- 
tory indeed.  This  is  the  beginning  of  the  ninth  year  in 
which  I  have  employed  ladies  in  this  field." 

Dr.  A.  M.  Xodine,  of  Xew  York,  suggests  that:    "It 


K     r/' 


1^       a-j 


The  Dental,  Nuese.  197 

would  be  a  migiity  fine  thing  for  the  dental  profession  to 
achieve  this  accomplishment  for  the  benefit  of  the  millions 
of  poor  school  children.  If  the  public  wakes  up  to  the 
realization  of  the  possibilities,  importance,  economy  and 
practicabilit}^  of  the  idea,  it  will  establish  the  trained 
nurse  in  spite  of  either  the  apathy  or  protest  of  the 
dental  profession." 

Along  the  same  line  of  prophesy,  Dr.  Kirk,  by  edi- 
torial in  Dental  Cosmos,  says : 

"Whatever  objections  may  be  urged  at  present 
against  the  emplo^'ment  of  the  dental  nurse  in  the  capac- 
ity here  under  consideration,  the  trend  of  the  time  ap- 
pears to  be  inevitably  in  favor  of  such  a  course,  and  it  is 
highly  probable  that  the  near  future  will  see  the  dental 
nurse  as  firmly  intrenched  in  her  field  of  activity  and  as 
efficiently  serviceable  therein  as  today  we  find  the  usual 
lady  assistant  in  our  modern  dental  offices." 

I  cannot  for  the  life  of  me  see  why  the  dentist  will 
undertake  even  the  operation  of  filling  the  teeth  without 
first  using  the  precaution  of  cleaning  the  field  of  opera- 
tion, I  have  made  it  a  rule  in  my  office  that  before  I  take 
the  patients,  I  turn  them  over  to  my  dental  nurse,  who, 
if  nothing  more,  mops  and  syringes  the  mouth  out  with 
antiseptic  solutions.  I  find  that  the  patient  appreciates 
the  work  more  and  that  it  lasts  longer,  and,  surely,  it  is 
more  pleasant  to  work  in  a  clean  mouth  than  in  a  dirty 
one.  Then  too,  when  I  have  finished  the  work  for  the 
patient,  he  is  again  turned  over  to  the  nurse,  who  suggests 
the  proper  toilet  articles  such  as  dentrifice,  silk,  mouth 
wash,  etc.  If  the  patient  desires',  these  are  furnished  him 
before  leaving  the  office. 

It  is  a  good  idea  to  keep  these  things  for  sale  in  the 
office,  as  it  gives  the  nurse  a  chance  to  earn  ]iart  of  her 
salary.  It  also  gives  the  nurse  the  opportunity  of  in- 
structing the  patients  in. the  manner  of  brushing  their 
teeth.     Few  patients  know  this,  and  the  dentist  is  too 


198  I       Peactical  Oeal  Pkophylaxis. 

busy  to  sliow  them  properly,  as  it  takes  some  fifteen  or 
twenty  minutes. 

You  will  find  in  the  case  of  the  younger  patients,  that 
if  they  had  to  be  led  in  to  you  first,  would  probably  be 
afraid  and  hard  to  manage.  The  dental  nurse  can  take 
these  children  for  a  few  sittings  and,  by  cleaning  up  their 
teeth  and  teaching  them  something  about  oral  hygiene, 
will  be  able  to  turn  them  over  to  you,  with  all  fears  dis- 
pelled, for  the  further  treatment  of  their  teeth. 

Women  are  particularly  adapted  to  the  work  of  pro- 
phylaxis in  that  the  sense  of  touch  is  more  delicate,  and, 
just  as  they  are  willing  to  spend  hours  working  on  a  small 
handl^erchief,  so  they  will  be  willing  to  work  for  a  long 
time  removing  stains  from  teeth  while  the  dentist  devotes 
his  time  to  other  work. 

There  are  many  patients  who  would  avail  themselves 
of  the  opportunity  for  prophylaxis,  but  who  are  not  will- 
ing to^  pay  a  dentist  for  his  time.  Thus  the  dental  nurse 
enables'  these  to  have  this  treatment  at  a  smaller  fee,  as 
the  dentist's  time  is  worth  from  $5.00  to  $10.00  per  hour, 
the  nurse's  is  worth  from  $1.00  to  $5.00  per  hour.  She 
can  spend  more  time  than  if  the  dentist  did  all  the  work 
himself.  In  the  course  of  time,  the  patient  begins  to  ap- 
preciate this  class  of  dental  work,  and  will  be  willing  to 
pay  regular  fees. 

Several  years  ago  when  I  first  determined  to  train  a 
nurse  for  some  of  my  work  I  advertised,  and  talked  with 
150  applicants  before  I  accepted  a  middle-aged  trained 
nurse  wlio  now  does  the  larger  part  of  this  work  in  my 
office.  She  first  helped  me  at  the  chair,  then  took  a  course 
by  reading  everything  published  on  the  subject ;  she  also 
brought  in  her  kinsfolk's  children  and  her  friends  to 
practice  on.  On  regular  patients  I  would  do  the  difficult 
part  and  have  hor  finish  the  treatment.  Thus  she  became 
jiroficient  and  solf-confidont,  while  tlio  patients  are  de- 
lighted with  the  novelty  of  the  idea. 


The  Dental  Nuese. 


199 


DR.    ROBIN    ADAIR 

RESPECTFULLY  ANNOUNCES  TO  HIS  PATIENTS 
THE  SERVICES  OF  A  TRAINED  DENTAL  NURSE 
TO  PRACTICE  ORAL  PROPHYLAXIS  UNDER  HIS 
DIRECTION    AT    A    MINIMUM    FEE. 

THE  TRAINING  OF  CHILDREN  IN  THE  PROPER 
CARE  OF  THEIR  TEETH  HER  SPECIALTY. 

Phone  Main   2442. 


The  above  card  was  sent  to  all  my  patients  to  let  them 
know  about  the  dental  nnrse.  When  I  saw  she  was  a  suc- 
cess I  quit  the  work,  except  to  those  who  were  willing 
to  pay  well  for  my  service,  and  sent  out,  as  ' '  per  sugges- 
tion by  Bro.  Bill,"  a  card  like  this: 


DR.    ROBIN    ADAIR 

RESPECTFULLY  ANNOUNCES  THAT  ON  DECEM- 
BER THE  FIRST  HIS  FEES  FOR  ORAL  PROPHY- 
LAXIS  WILL  BE   ADVANCED. 

November   26,    1909. 


In  regard  to  the  dental  nurse  I  can  only  say  that  when 
the  proper  help  is  secured  it  not  only  adds  dignity  to  the 
dental  office,  but  also  enlarges  the  field  of  the  dentist. 

To  those  who  contemplate  taking  a.stand  for  the  legal 
status  of  female  dental  assistants  the  following  sugges- 
tions Avere  given  by  Dr.  F.  H.  Skinner,  of  Chicago,  after 
a  lengthy  conference  with  him  on  this  subject.  In  view  of 
the  fact  that  we  have  no  institution  where  instruction  is 
given  the  nurses  he  gives  a  plan  whereby  they  may  be 
trained  and  leo-alized. 


AN"  ACT  TO  EEGULATE  THE  PRACTICE  OF   ORAL  PROPHYLAXIS  BY 

A  REGISTERED  DENTAL  ASSISTANT,  BY  F.  H.  SKINNER,  D.  D.  S. 

REQUIREMENTS   FOR   APPLICATION. 

1.  Application  for  license 'must  be  made  to  the  State 
Board  of  Dental  Examiners,  and  signed  by  a  regular 
registered  dental  practitioner. 


200  Peactical  Oeal,  Prophylaxis. 

2.  Party  for  whom  application  is  made  must  be 
twenty-one  years  old  and  graduated  from  an  accredited 
high  school. 

3.  Said  party  must  have  had  at  least  three  years 
experience  as  a  dental  assistant  under  a  licensed  dental 
practitioner  who  vouches  for  applicant's  efficiency  and  a 
certain  knowledge  of  the  few  drugs  and  medicines  used 
in  oral  prophylaxis. 

LICENSE. 

Upon  such  application  being  presented  to  the  State 
Board  of  Dental  Examiners,  that  body,  at  its'  discretion, 
shall  issue,  or  cause  to  be  issued,  a  license  permitting  the 
j3arty  named  to  practice  oral  prophylaxis  only  in  the 
office  of  the  practitioner  who  signs  the  application,  or 
such  place  as  he  may  request.  (As  a  call  at  a  home  to 
give  an  oral  prophylaxis  treatment,  in  case  of  sickness.) 

The  State  Board  has  a  right  to  satisfy  itself  as  to  the 
qualifications  of  the  applicant,  as  to  the  education,  age 
and  character,  as  well  as  by  examination  as  to  ability, 
and  if  deemed  advisable,  require  applicant  to  give  a 
clinic  to  satisfy  itself,  or  it  may  issue  license  solely  upon 
the  reputation  of  the  dental  practitioner  who  signs  the 
application. 

FEES. 

The  fee  for  said  license  shall  be  $10.00  (ten  dollars) 
and  shall  be  subject  to  the  same  registration  and  fees  as 
the  license  of  a  practicing  dentist. 

Should  the  party  to  whom  license  is  issued  leave  the 
employ  of  the  practitioner  who  signs  the  application, 
said  license  becomes:  null  and  void,  but  a  new  license  may 
be  issued  without  examination  should  the  party  enter 
the  employ  of  another  dentist.  The  object  of  this  is  to 
have  this  work  done  always  under  the  supervision  or  con- 
trol of  a  regular  dental  practitioner. 

A  committee  from  the  Massachusetts  Dental  Society 
drew  up  and  presented  a  bill  for  legislative  enactment 


The  Dental  Nuese.  201 

giving  a  legal  standing  for  the  dental  nurse  and  the 
methods  of  control.  The  object  of  this  bill  was  thus  urged 
by  the  committee : 

''The  object  of  the  bill  is  to  secure  for  the  dental  pro- 
fession the  help  in  practice  furnished  physicians  and 
surgeons.  By  our  present  dental  law  the  dentist  cannot 
legally  have  this  needed  assistance.  Even  the  registered 
nurse  while  doing  work  among  the  poor,  cannot  examine 
the  mouth  of  a  child  suffering  with  toothache  and  put  in 
anything  to  relieve  the  child's  distress  without  breaking 
the  dental  law.  So  slight  an  operation  as  tying  a  piece  of 
silk  or  putting  a  piece  of  tape  between  teeth  for  wedg- 
ing, is  illegal  when  not  done  by  a  registered  dentist.  No 
one  but  a  registered  dentist  may  clean  or  polish  teeth. 
This  makes  it  impossible  for  children's  teeth  to  be  prop- 
erly cared  for,  as  the  busy  dentist  cannot  devote  time 
enough  to  this  operation,  and  in  order  to  have  it  done  as 
often  as  needed,  it  becomes  a  financial  burden  for  a  fam- 
ily of  limited  income  at  the  price  a  registered  dentist  must 
charge  for  his  time.  In  the  public  clinic  the  registered 
dentist  can  do  practically  nothing  in  polishing  the  chil- 
dren's teeth. 

"The  prophylactic  care  of  children's  teeth  is  therefore 
not  practicable  with  our  present  legal  conditions.  In 
order  that  the  children  may  have  this  proper  care,  the 
public  needs  a  dental  nurse.  This  nurse  need  not  have 
at  present  the  extended  training  that  is  given  a  register- 
ed nurse.  The  training  that  she  will  receive  in  the  train- 
ing schools  will  give  the  dental  profession  a  standard  of 
service  that  we  have  never  had.  There  are  many  young- 
women  employed  in  the  dental  offices  of  our  State  who  by 
being  trained  and  being  registered  as  dental  nurses  would 
be  of  invaluable  aid  to  their  employers.  No  one  need, 
however,  employ  sucli  a  nurse.  The  regular  office  assis- 
tant will  be  used  as  formerly,  only  she  may  not  do  the 
things  the  registered  dental  nurse  may  do,  and  of  course 
she  will  lack  the  training." 


202  Practical  Oeal  Prophylaxis. 

HOUSE   ....   No.  1566 

The  Commonwealth  of  Massachusetts 
111  the  Year  One  Thonsaiid  Nine  Hundred  and  Twelve. 

AN  ACT 

To   amend  the  law   regulating  the  pactice  of   dentistry. 

Be  it  enacted  by  the  Senate  and  House  of  Representatives  in  General 

Court  assembled,  and  by  the  authority  of  the  same,  as  follows : 

Section  1.  Anj-  i^^i'son  who  is  eighteen  years  of  age  or  over  and 
in  the  opinion  of  the  Board  of  good  moral  character,  upon  payment  of 
a  fee  of  five  dollars,  which  shall  not  be  returned  to  him,  may  upon 
application  be  examined  by  the  Board  of  Registi'ation  in  Dentistry 
and  be  licensed  by  said  Board  as  provided  in  Section  six  hereof  to  per- 
fonn  such  sen'ice  as  a  dental  nurse  as  shall  be  si^ecified  in  his  license. 
ExcejDt  as  provided  in  Section  two  in  this  Act,  the  person  desiring 
such  registration  shall  specify  in  his  application  the  name  and  address 
of  the  registered  dentist  by  whom  he  is  to  be  employed,  and  this  ap- 
plication shall  be  approved  in  writing  by  such  registered  dentist.  No 
registered  dentist  shall  have  at  one  time  more  than  one  registered 
dental  nurse  in  his  emplo3"ment,  No  business  firm  or  private 
incorporated  dental  company  shall  employ  more  than  one  registered 
dental  nurse  at  one  time,  in  auj  office  managed  or  ow^led  by  it.  Such 
license  shall  be  valid  for  one  year  from  the  date  thereof  unless  revoked 
by  said  Board  for  the  violation  of  the  conditions  thereof.  Any  license 
issued  under  the  provisions  of  this  Section  may  be  renewed  without 
further  examination  in  the  discretion  of  the  Board,  from  year  to  year, 
upon  pajTnent  of  a  fee  of  five  dollars. 

Sec.  2.  Any  person  who  is  eighteen  yeai-s  of  age  or  over  and  in 
the  opinion  of  the  Board  of  good  moral  character  may,  upon  applica- 
tion, be  examined  by  said  Board  and  licensed  as  aforesaid  to  serve  as 
a  dental  nurse  in  any  of  the  public  educational  or  charitable  institu- 
tions in  the  state  approved  by  said  Board,  which  institution  shall  be 
specified  in  the  license,  provided  that  this  application  shall  be  endoi-sed 
by  the  authorized  officers  of  such  institution.  Such  license  shall  be 
limited  to  the  performance  of  service  in  connection  Avith  institutions 
of  the  character  specified  therein  and  may  be  renewed  from  year  to 
year  without  further  examination  and  without  the  payment  of  any 
fee  therefor.  Any  number  of  dental  nurses  may  be  licensed  for  ser- 
vices in  connection  with  any  such  institution.  Any  license  issued  un- 
der the  provisions  of  this  Section  shall  expire  forthwith  whenever  the 
I'egistcred  dental  nui-se  shall  cease  to  render  such  services  solely  for 
institutions  of  the  character  sjiecified  in  the  license. 

Sec.  .3.  A  registered  dental  nui-se  shall  be  licensed  to  perform  only 
such  duties  as  shall  be  si^eeified  in  his  license  and  solely  in  the  offica 
and  under  the  direction  of  a  registered  dentist.     No  dental  nurse  shall 


Peoposed  Dental  Nukse  Law.  203 

be  licensed  to  perform  any  service  other  than  the  examination,  wedg- 
ing and  cleaning  exposed  surfaces  of  teeth,  inserting  and  changing 
dressing's  in  teeth  for  the  relief  of  pain  and  assisting  a  registered  den- 
tist during  the  jDerformance  of  his  dental  operations. 

Sec.  4.  Any  member  of  said  Board  or  its  agent  may  at  any  time 
visit  any  office  or  institution  in  which  a  licensed  dental  nurse  shall  be 
employed  and  make  such  examination  as  he  shall  see  fit  in  order  to 
determine  whether  the  pro\-isious  of  the  laws  regulating  the  practice  of 
dentistry  and  dental  nursing  have  been  complied  with. 

Sec.  5.  Any  licensed  dental  nurse  changing  employers  must  notify 
the  Board  forthwith  of  such  change  and  also  of  the  name  and  address 
of  the  dentist  by  whom  he  is  to  be  employed. 

Sec.  6.  Whenever  by  the  terms  of  such  license  the  holder  thereof 
shall  be  authorized  to  perform  all  of  the  ser\-ices  specified  in  Section 
three  hereof,  and  shall  have  the  title  of  Registered  Xurse,  such  holder 
shall  have  the  right  to  use  the  title  Registered  Dental  Nurse.  An  ap- 
plicant who  fails  to  pass  an  examination  satisfactory  to  the  Board,  and 
is  therefore  refused  registration,  shall  be  entitled  -within  one  year  after 
such  refusal  to  a  re-examination  at  a  meeting  of  the  Board,  called  for 
the  examination  of  applicants  Avithout  the  payment  of  an  additional 
fee. 

Sec.  7.  The  Board  may,  after  a  hearing,  by  a  vote  of  a  majority 
of  its  membei's,  annul  the  registration  and,  without  a  hearing  may 
annul  the  registration  and  cancel  the  license  of  a  dental  nurse  who 
has  been  found  guilty  of  a  crime  or  misdemeanor. 

Sec.  8.  The  Board  shall  have  power  to  register  in  like  manner, 
without  examination,  any  person  who  has  been  registei-ed  as  a  pro- 
fessional dental  nui^e  in  another  state  under  laws  which  in  the  opinion 
of  the  Board  maintain  a  standard  substantially  equivalent  to  that  of 
this  Act. 

Sec.  9.  The  Board  shall  investigate  all  complaints  of  violation  of 
the  provisions  of  this  Act.  and  rei^ort  the  same  to  the  proper  prose- 
cuting officers. 

Sec.  10.  "Whoever,  not  being  authorized  to  practice  as  a  registered 
dental  nui-se  within  this  Commonwealth,  practices  or  attempts  to  prac- 
tice as  a  registered  dental  nui"se,  or  uses  the  abbreviation  R.  D.  N.,  or 
any  other  words,  letters  or  figures  to  indicate  that  the  pei"son  using  the 
same  is  a  registered  dental  nurse,  shall  for  each  offense  be  punished 
by  a  fine  of  not  more  than  one  hundred  dollai-s.  Whoever  becomes 
registered  or  attempts  to  become  registered,  or  whoever  practices  or 
attempts  to  practice  as  a  registered  dental  nurse  imder  a  false  or 
assumed  name,  shall  for  each  offense  be  punished  by  a  fine  of  not  more 
than  one  himdred  dollai-s,  or  by  imprisonment  for  tkree  months,  or 
by  both  such  fine  and  imprisonment. 

Sec.  11.     This  Act  shall  take  effect  upon  its  passage. 


CHAPTER     XXI. 

TEACHING  OF  OEAL  HYGIENE,  PROPHYLAXIS 
AND  PYORRHEA  IN  DENTAL  COLLEGES. 

PRACTICAL   METHODS  EMPLOYED  BY  THE  AUTHOR. THE 

RESULTS   OBTAINED. THE  NEED  OF  SUCH   INSTRUCTION. 

Tlie  subjects  of  oral  hygiene,  prophylaxis  and 
pyorrhea  are  receiving  more  and  more  attention  each 
year  in  our  dental  colleges.  Having  tanght  these  sub- 
jects for  several  years,  I  give  some  suggestions  that  may 
prove  of  value  to  those  just  beginning  the  work. 

If  practical,  the  course  should  be  divided  as  follows : 
Freshmen  receive  the  course  on  oral  hygiene,  the  Juniors 
prophylaxis  and  the  Seniors  pyorrhea.  In  order  to  make 
the  lectures  of  a  personal  character  and  to  elicit  personal 
interest,  it  is  best  to  make  a  personal  examination  of  the 
mouths  of  each  class  and  tabulate  the  result.  Call  at- 
tention to  any  defect  or  treatment  needed.  The  students 
should  be  called  into  a  private  room,  one  at  a  time,  for  the 
examination.  Before  final  examinations  another  exami- 
nation should  be  made  and  credit  mark  given  for  any 
improvement.  If  the  lectures  have  been  interesting,  this 
makes  the  work  of  practical  value.  If  this  is  not  done,  or 
where  no  lectures  have  been  given  on  these  subjects,  wa 
find  many  Seniors  going  out  with  their  mouths  in  a  con- 
dition which  is  a  disgrace  to  the  profession,  which  they 
will  represent. 

At  the  first  lecture  take  into  the  hall  a  new  tooth-brush, 
floss  silk,  fjuill  tooth  pick  and  dentifrice.  Ask  for  a  vol- 
unteer from  the  class  to  come  to  the  rostrum.  Give  him 
the  tooth  brush  with  the  request  that  he  brush  his  teeth 
exactly  as  he  practiced  at  home.  He  generally  will  make 
a  poor  showing.  Then  take  the  brush  in  your  own  hands 
and  brush  the  teeth  correctly.  See  that  the  student  can 
do  this  correctly  before  he  leaves  the  stand.     Then  ex- 


Teachhstg  Hygiene,  PbophyijAxis,  Pyorrhea.      205 

plain  to  the  class  that  if  a  student  of  dentistry  does  not 
know  how  to  brush  his  teeth,  they  can  expect  their 
j)atients  to  know  less.  The  use  of  the  silk  and  other 
accessories  are  also  shown.  The  demonstration  of  the 
proper  method  of  rinsing  the  mouth  is  sometimes  a  reve- 
lation even  to  a  Senior  student. 

In  teaching  prophylaxis,  it  is  well  to  divide  the  class 
into  sections  of  twenty  each.  Take  one  section  into  the 
dental  infirmary.  Seat  one-half  of  them  in  dental  chairs 
and  have  the  other  ten  get  out  their  prophylaxis  instru- 
ments and  go  to  work  on  those  seated.  Go  from  chair  to 
chair,  showing  each  individually  how  to  hold  their  instru- 
ments. At  the  next  clinic  the  men  who  did  the  work  be- 
fore are  seated  in  the  chairs  and  the  others  put  to  work. 
This  may  be  repeated  with  each  section  until  every  mem- 
ber of  the  class  has  his  mouth  put  in  good  condition. 
Many  of  their  gums  will  be  cut  with  instruments,  tissues 
lacerated  and  plenty  of  calculus  left  on  their  teeth.  How- 
ever, it  will  be  worth  all  the  discomfort  they  endure,  for 
it  teaches  them  the  best  lesson  possible.  As  you  proceed 
with  the  course  induce  the  boys  to  take  monthly  prophy- 
laxis treatments  among  themselves. 

One  of  the  most  convincing  arguments  for  a  perma- 
nent interest  is  for  the  teacher  to  exhibit  some  of  his 
private  patients  who  have  been  on  prophylaxis  for  some 
time,  just  to  show  them  what  can  be  accomplished. 

In  teaching  pyorrhea,  the  cases  which  were  found  in 
the  examination  of  the  students'  mouths  should  be  used 
for  clinical  material,  so  that  the  various  treatments  can 
be  given  mider  their  direct  observation.  If  several  cases 
be  under  treatment  they  should  be  turned  over  to  the 
students  for  dressing  and  applications  and  the  progress 
closely  watched  by  the  professor.  No  set  method  of  deal- 
ing with  this  lesion  should  be  given,  but  demonstrate  all 
procedures  which  seem  to  have  any  virtue. 

One  session  the  writer  noticed  that  the  students  of  the 
Senior  class  were  lacking  in  practical  application  of  his 


206  Practical  Oral  Prophylaxis. 

efforts  to  have  them  carry  off  the  spirit  as  well  as  the 
letter  of  his  lectures.  This  following  notice  was  posted 
in  the  bulletin : 

"To  THE  Senior  Class:- 

"Without  further  notice,  an  examination  of  the 
mouths  of  the  Senior  Class  is  soon  to  be  made  and  the 
mark  given  at  this  time  will  count  on  the  final  examina- 
tion. Any  one  presenting  an  unclean  or  diseased  mouth 
will  not  receive  my  name  on  his  diploma." 

The  report  soon  came  to  me  from  the  demonstrator  in 
the  Infirmary  that  he  could  not  get  any  work  out  of  the 
boys,  because  they  were  so  busy  cleaning  up  each  other's 
mouths.  When  the  graduating  exercises  took  place,  it 
was  my  pleasure  to  know  that  the  Senior  Class  presented 
the  cleanest  mouths  of  any  class  that  had  ever  gone  out 
of  the  institution,  and-I  believed  that  many  of  them  would 
be  future  missionaries  along  this  line  of  work.  Later 
results  have  shown  that  this  supposition  was  correct, 
for  I  have  heard  of  the  members  of  the  class  giving  lec- 
tures before  the  schools  in  the  various  towns  and  leading 
in  school  inspection  work.  Most  colleges  now  have  some 
lectures  on  this  subject,  and  a  few  of  them  have  regular 
chairs,  and  it  is  to-  be  hoped  that  a  greater  number  will 
see  the  wisdom  of  giving  this  subject  the  importance 
which  it  deserves. 

Of  interest,  showing  the  trend  of  the  times  towards 
teaching  this  subject  in  the  dental  colleges,  is  the  follow- 
ing statement  from  Dr.  G.  V.  Black,  of  the  Northwestern 
Dental  University  School,  who,  in  a  letter  to  me,  April  4, 
1913,  says,  "I  have  been  silent  on  this  subject  for  a  num- 
ber of  years.  In  fact,  I  have  not  written  anything  since 
the  article  for  the  American  System  of  Dentistry,  until 
quite  recently,  but  a  couple  of  years  ago  I  re-arranged 
the  curriculum  somewhat,  and  took  this  subject  myself, 
on  purpose  to  have  the  opportunity  of  giving  my  time  to 
it,  and  of  finally  writing  what  I  might  wish  to  say." 

Dr.  N.  S.  Hoff,  of  the  University  of  Michigan,  in 


Teaching  Hygiene,  Pkophylaxis,  Pyorrhea.       207 

answer  to  my  iuquiiy  of  his  vie\Y.s  on  tliis  subject,  wrote 
me  March  1,  1913,  "The  need  for  this  work  is  tremen- 
dous, and  I  sometimes  feel  as  though  it  is  a  particular 
form  of  work  whicli  will  have  to  be  done  independent 
of  the  dental  college  work,  as  I  am  eonhdent  when  it  is 
taken  into  dental  college  work,  it  will  absorb  so  much  of 
the  time  that  other  forms  of  instruction  will  suffer,  just 
as  I  have  found  it  to  do  in  private  practice.  It  is  imprac- 
tical to  do  this  work  in  connection  with  the  general 
practice  for  the  reason  that  it  absorbs  so  much  time.  The 
dentist  becomes  so  much  interested  in  it  that  he  is  not 
willing  to  allow  any  patient  to  go  until  he  has  given  him 
a  complete  treatment,  and  when  this  is  undertaken,  neces- 
sarily other  lines  of  work  must  be  set  aside." 

Dr.  C.  M.  Gearhart,  chairman  of  the  oral  hygiene  sec- 
tion of  the  National  Dental  Association  for  1912,  writes 
me  an  interesting  letter,  from  which  I  quote  as  follows: 

"I  have  been  struggling  for  years  teaching  'Oral 
Hygiene  and  Prophylaxis'  in  Georgetown  University 
without  a  text-book.  Oral  hygiene  covers  such  a  multi- 
tude of  sins  that  I  have  found  it  necessary,  in  a  way,  to 
have  to  review,  or  rather  lapse  over  subjects  taught  Iw 
other  men  in  Georgetown,  in  order  to  make  the  subject 
worthy  of  giving  it  a  course.  It  has  always  seemed  to 
me  that  the  teaching'  of  oral  hygiene  is  something  more 
than  merely  explaining  to  students  that  they  should  keep 
their  own,  and  advise  their  patients  to  keep  their  mouths 
clean." 

It  is  hoped  that  this  book  will,  in  some,,  degree,  meet 
the  requirements  along  this  line,  and  that  it  may  stimu- 
late other  teachers  of  this  subject  to  record  their  ex])eri- 
ences  and  methods  of  teaching. 


PART  III. 

A  PRACTICAL  DESCRIPTION  OF  PYORRHEA  ALVEOLARIS 
AND  ITS  TREATMENT 


CHAPTER     XXII. 
PYORRHEA  ALVEiOLARIS. 

SYNONYMS. DEFINITION. CAUSES. 

WHAT    IS    TARTAR   AND    ITS  FORMATION ! KINDS    OF    CALCULI, 

AND  DEPOSITS. BLACK 's  THEORY. 

Authorities  in  general  medicine  and  surgery  have  in 
a  scientific  way  decided  upon  a  certain  frame  work  for 
the  description  of  any  disease.  Failure  to  adhere  to  this 
frame  work  by  dentists  is  one  of  the  reasons  why  we 
have  not  come  upon  any  common  ground  in  our  writing 
on  pyorrhea.  Having  received  reprints  by  the  hundred, 
written  by  the  most  prominent  men  in  the  profession,  1 
find  that  they  vary  greatly  in  describing  pyorrhea  and 
do  not  adhere  to  the  commonly  accepted  .methods  of 
description.  The  frame  work  used  for  the  description 
of  pyorrhea  should  be:  1,  synonyms;  2,  definition;  3, 
causes;  4,  pathological  anatomy;  5,  symptoms;  6,  diag- 
nosis ;  7,  prognosis ;  8,  treatment. 

If  we  notice  the  various  reprints  on  pyorrhea,  we  will 
find  that  in  some  of  them  the  prognosis  is  described  first, 
probably  the  same  paper  ending  with  pathological 
anatomy.  It  would  greatly  simplify  matters  if  writers 
and  teachers  of  this  subject  would  describe  it  in  a  sys- 
tematic manner. 

SYNONYMS. 

Here  we  have  such  a  large  and  unfortunate  list  that 
the  student  is  completely  bewildered  in  his  selection : 

Pyorrhea  alveolaris,  Riggs'  disease  (Bishop),  infec- 
tious alveolitis,  cemento  periostitis,  calcic  inflammation 
(Black),  blenorrhea  alveolaris,  hematogenic  pericemen- 


212  Peactical  Pyoeehea  Alveolaeis. 

titis,  pliagadenic  pericementitis  (Black),  chronic  alveo- 
litis, interstitial  gingivitis  (Talbot),  periostitis  dentales 
(Schiff),  alveolar  pyorrhea  (Smith),  chronic  alveolar 
ostomyelitis  (Medalia),  oral  sepsis  (Hunter,  of  London). 
Edematous  perideutitis,  hypertrophic  peridentitis, 
suppurative  peridentitis,  gangrenous  peridentitis  (Hoff). 

Dr.  H.  M.  Fletcher,  of  Cincinnati,  urges  the  adoption 
of  the  following  classification: 

Initial  or  simple  alveolitis,  non-suppurative  alveolitis, 
suppurative  alveolitis,  necrotic  alveolitis,  acute  alveolitis, 
descriptive  subdivisions : 

Chronic  non-suppurative  alveolitis, 

Chronic  suppurative  alveolitis. 

Necrotic  non-suppurative  alveolitis  (always  chronic). 

Necrotic  suppurative  alveolitis,  (nearly  always 
chronic  but  may  be  acute). 

Zentler,  of  New  York,  suggested  the  name  alveolar- 
dental-arthritis,  classifying  it  as  the  primary,  secondary 
and  tertiary  dental  arthritis. 

Dr.  M.  L.  Rhein  classifies  pyorrhea  by  the  addition 
of  adjectives  stating  the  name  of  the  disease  which  he 
thinks  causes  the  symptoms  i.  e.  "Diabetic  Pyorrhea" 
and  ''Tubercular  Pyorrhea."  Prof.  W.  D.  Miller,  in 
his  text  book  on  pyorrhea,  adopted  this  classification. 

Dr.  Eehwinkel  first  called  it  pyorrhea  alveolaris  in 
1877,  in  the  city  of  Chicago,  although  the  name  was  used 
in  France  as  far  back  as  1870. 

Black  called  it  phagadenic  pericementitis  in  1882, 

The  author  is  not  convinced  that  any  one  of  the  above 
should  be  accepted.  Common  usage  at  the  present  time 
ahnost  compels  us  to  use  the  terim;  pyorrhea  alveolaris 
until  a  better  term  is  suggested  and  adopted. 

Ill  llie  Soutli  many  dentists  prefer  the  term  ''Riggs' 
Disease,"  hccanse  tlie  older  practitioners  believed  that 
the  honor  for  the;  beginning  of  the  surgical  work  should 


Pyoerhea  Alveolams. — Definition.  213 

be  given  to  Dr.  John  M.  Riggs,  of  Hartford,  Conn.,  as  he 
was  the  first  man  to  advocate  a  treatment  or  even  to  say 
that  it  could  be  cured.  The  same  sort  of  sentiment 
IH'ompted  this  naming  as  the  calling  of  interstitial  neph- 
ritis '' Bright 's  Disease."  In  later-day  nomenclature,  the 
fault  of  this  method  of  adopting  names  has  been  realized 
and  efforts  are  being  made  to  change  many  of  them. 

DEFINITION. 

The  late  Chas.  B.  Atkinson,  of  New  York,  defines  this 
condition  as  "a  disease  following  congestion  of  the 
myxomatous  tissue  of  the  oral  cavity,  affecting  with  wide 
range  of.  loss,  the  gingivae,  alveoli,  and  teeth,  from  slight 
recession  of  the  gums  to  entire  solution  of  alveolus,  and 
the  consequent  loss  of  tooth  or  teeth  involved;  therefore, 
perhaps  more  properly  'pyogenic  gingivitis." 

Dr.  C.  N.  Peirce  describes'  it  as  follows:  ''A  chronic 
inflammation  of  the  pericemental  membrane,  attended  by 
a  congested,  spongy  and  tumefied  condition  of  the  gums 
and  mucous  membrane,  and  usually  accompanied  by  a 
persistent  flow  of  pus  from  the  alveolar  sockets.  In  the 
progress  of  the  disease  the  alveolar  process,  under  the 
influence  of  engorgement  of  the  periosteal  vessels,  be- 
comes involved  and  eventually  undergoes  atrophy  or 
absorption,  leading  to  an  exfoliation  of  practically  nor- 
im,al  teeth,"  and  ascribes  its  etiology  to  the  uric  acid 
diathesis  of  the  patient. 

Dr.  G.  V.  Black  describes  it  as  ''a  specific  infectious 
inflammation  having  its  beginning  in  the  gingivae,  and 
accompanied  with  the  destruction  of  the  peridental  mem- 
branes and  alveolar  walls,"  and  while  not  committing 
himself,  says  that  probably  it  is  caused  by  the  iDresence 
of  some  peculiar  form  of  micro-organism  and  that  it  is 
infectious. 

Dr.  Rhein  defines  it  as  folloAvs:  "'\^^nle  pyorrhea 
alveolaris  literally  means  a  discharge  of  pus'  from  the 


214  Practical,  Pyorrhea  Alveolaris. 

alveolus,  the  simplest  definition  of  its  pathogenic  condi- 
tion commonly  accepted  under  the  term  would  be  that 
it  represents  a  diseased  condition  of  the  peridental 
region  due  to  impaired  nutrition." 

Dr.  D.  D.  Smith  says,  "mouth  pyorrhea  is  a  disease 
of  uncleanliness. " 

Dr.  W.  J.  Younger  preferred  the  name  pyorrhea 
alveolaris  and  gave  this  definition:  "Pyorrhea  alveolaris 
is  characterized  by  an  inflammation  of  the  gums  and  a 
deposit  of  characteristic  greenish  gray  or  slate  colored 
tartar  and  the  wasting  of  the  alveoli  accompanied  by  the 
formation  of  pus  and  pus  pockets  between  the  tooth  and 
alveolus ;  the  disease  being  due,  as  I  believe,  to  a  specific 
bacillus.  The  disease  is  chronic  in  its  duration  and  re- 
sults in  the  ultimate  loss  of  the  teeth.  This  slate  colored 
incrustation  of  which  I  have  spoken,  I  consider  pathogno- 
monic of  the  disease." 

Pickerill  in  his  book  on  "O'ral  Sepsis"  gives  the  fol- 
lowing definition: 

"Pyorrhea  alveolaris  is  essentially  a  suppurative 
process  occurring  in  the  joint  around  the  tooth  between 
it  and  the  jaw  bone;  it  may  be  localized  or  general,  but 
usually  is  found  associated  with  groups  of  several  con- 
tiguous teeth." 

CAUSES. 

The  etiology  of  pyorrhea  is  given  as  local  and  con- 
stitutional. A  few  years  ago  the  latter  was  advocated 
by  many  of  the  leading  men  of  the  profession  and  many 
valuable  papers  were  published  and  read  upon  "Uric 
Acid  Diathesis,"  "Kheumatism,"  etc.,  as  the  etiologic 
factor,  but  today  those  who  are  making  the  greatest 
success  of  their  treatment  are  almost  unanimous  in  their 
opinion  that  local  causes  would  be  decided  upon  as  the 
greatest  factor. 

It  is  not  denied  that  the  general  systemic  condition 
of  the  patient  has  an  influence  and  must  be  looked  into 


Pyoekhea  Alveolaeis— Causes.  215 

and  treated,  but  this  should  be  considered  as  only  a  pre- 
disposing factor  or  complication  of  the  pyorrhea.  Per- 
sonally, the  author  believes  that  if  a  mouth  is  maintained 
in  a  good  condition,  with  the  absence  of  local  causes  liere- 
after  mentioned,  no  systemic  disorder  would  ever  pro- 
duce a  case  of  alveolar  pyorrhea.  In  other  words,  there 
are  no  systemic  reasons  for  the  cause  of  pyorrhea  other 
than  those  which  may  predispose  to  any  disease. 

Younger  claims  that  temperament  has  no  bearing  on 
this  disease,  while  Smith  opposes  this  view  with  the  dec- 
laration that  pyorrhea  never  develops  in  the  puTely 
sanguine  but  always  in  the  bilious,  the  lymphatic,  and 
the  nervous  temperament,  impaired  nutrition,  heredity, 
constitutional  disorders,  excessive  lime  salt  secretion, 
uric  acid  salts,  scurvy,  luxury  and  modern  degeneracy, 
sedentary  habits,  toxic  agents  introduced  into  the 
system,  chronic  infections,  and  the  eruptive  fevers  have 
also  been  named  as  causative  agents  of  pyorrhea 
alveolaris. 

In  answer  to  those  who  hold  the  above  causes 
Hutchinson  says : 

''I  have  no  doubt  that  in  cases  where  diabetes, 
syphilis  or  other  serious  systemic  disorders  are  coinci- 
dent with  pyorrhea,  the  pyorrhea  antedates  the  constitu- 
tional disorder  and  has  been  accentuated  but  not  caused 
by  such  disorder.  If  such  mouths  had  always  been  under 
prophylactic  treatment  I  believe  there  would  be  no 
pyorrhea.  The  amount  of  tissue  lost,  both  hard  and  soft, 
indicates  that  the  process  of  destruction  has  covered  a 
period  of  many  years  and  could  not  have  taken  place 
within  a  comparatively  short  time.  Usually  pyorrhea  in 
some  stage  exists  long  before  it  becomes  manifest  to 
either  the  patient  or  the  dentist,  and  so  the  error  of  be- 
lieving it  to  be  of  recent  occurrence  is  often  made." 

The  initial  cause  of  pyorrhea  is  sometimes  so  small 
and  simple  as  to  be  overlooked.  As  before  stated,  the 
object  of  this  book  is  to  be  of  a  practical  value  and  onh^ 


216  Pkacticax.  Pyorehea  Alveolaeis. 

the  causes  that  we  positively  know  and  see  every  day  are 
given : 

1st,  Deep  interlocking  cusps  on  bridge  work,  causing 
too  great  an  irritation  on  the  abutments  and  setting  up 
inflammation  in  the  membrane  supporting  them,  finally 
giving  rise  to  pyorrheal  conditions. 

2d,  Wing  bridges. 

3d,  Bad  bridge  work. 

4th,  Partial  dentures  which  may  have  any  kind  of 
swing  on  one  tooth. 

5th,  Ligatures,  clamps,  wedges  in  ordinary  dental 
operations  where  the  contusion  of  the  gum  margin  is  not 
treated  after  their  removal. 

6th,  Mal-occlusions  of  natural  cusps,  fillings,  or 
crowns.  Whether  mal-occlusion  is  a  cause  or  result  of 
l^yorrhea,  there  can  be  no  doubt  about  its  importance, 
no  matter  what  the  treatment  may  be.  One  of  the  great- 
est aids  is  in  grinding  down  markedly  prominent  cusps 
and  in  putting  out  of  action  those  teeth  which  are  weak- 
ened by  this  disease.  The  best  method  of  determining 
this  is  to  place  the  index  finger  longitudinally  across  the 
teeth  and  then  let  the  patient  close  the  mouth,  and  shake 
the  teeth.  If  this  discloses  the  fact  that  the  affected 
tooth  is  being  moved  to  a  greater  extent  than  the  others, 
it  is  an  indication  that  too  much  stress  is  being  placed 
thereon. 

Dr.  R.  G.  Hutchinson,  Jr.,  of  New  York,  says:  ''Of 
late  I  have  been  more  impressed  with  the  importance  of 
mal-occlusion,  either  general  or  localized,  as  a  prime 
factor  in  the  establishment  of  pyorrhea,  and  my  first  at- 
tention is  given  to  this  correction  by  grinding." 

7th,  In  the  disturbance  of  the  contact  point  of  the 
teeth,  whether  it  be  from  a  small  separation,  or  from 
malshaped  points,  allowing  food  fibres  to  pack  in  and 
gain  a  point  of  vantage  for  future  destruction.    A  large 


Pyorrhea  Alveolaris. — Causes.  217 

number  of  pyorrhea  pockets  are  undoubtedly  formed  in 
this  way,  the  so-called  "meat  holes." 

8th,  One  of  the  most  unbearable  forms  of  pain  in  the 
mouth  is  caused  by  the  abuse  of  wood  tooth  picks  and 
floss  silk.  Splinters  of  the  picks  break  off  in  the  mouth 
and,  when  the  patient  comes  for  treatment,  we  sometimes 
are  not  able  to  find  the  cause  of  the  inflammation.  This, 
in  time,  causes  loosening  of  the  point  of  contact,  allow- 
ing further  inroads  into  these  inflamed  surfaces. 

9th,  Any  mechanical  irritation  lodged  under  the  free 
margin  of  the  gums  surrounding  the  tooth  will  set  up 
initial  lesions.  Shedding  bristles  from  tooth  brushes, 
small  seeds,  grit  (possibly  left  from  cleaning  the  teeth), 
•skin  flakes  from  vegetables  or  fruit — any  one  may  cause 
this.  Tlie  gum,  being  unable  to  free  itself  from  this 
irritation,  inflammation  follows,  affecting  the  peridental 
attachment  and  the  alveolus. 

10th,  Tartar  formation:  AYhile  it  is  true  some  cases 
of  pyorrhea  do  exist  where,  seemingly  there  is  no 
deposit  of  tartar  present,  they  are  in  such  minority  as 
to  be  a  rare  exception.  Such  cases  may  at  one  time  have 
had  this  formation ;  furthermore,  such  minute  i^articles 
can  start  trouble  that  we  cannot  say  with  certainty  but 
that  all  cases  have  some  form  of  tartar  which  must  be 
removed  in  our  treatment.  In  fact,  the  greatest  factor 
in  the  successful  treatment  of  this  condition  is  the  finding 
and  complete  removal  of  tartar. 

11th,  Uncleanliness :  Last  and  probably  the  most  im- 
portant and  most  frequent  cause  of  pyorrhea  is  that  at 
some  period  of  the  patient's  life  there  was  a  lack  of  in- 
telligent care  of  the  mouth.  A  volume  might  be  written 
on  the  causes  of  pyorrhea,  but  we  have  to  admit  that  the 
greatest  factor  we  have  to  deal  with  is  uncleanliness  of 
the  mouth.  The  first  section  of  this  book  deals  in  full 
with  this  cause. 


218  Practical  Pyorehea  Alveolaeis. 

what  is  taetar  aitd  how  does  it  foem  ? 

Tartar  is  a  concreting  material,  either  secreted  or 
concreted  in  the  month  from  the  saliva,  which  is  deposited 
on  the  teeth  or  artificial  dentures.  Various  hypotheses 
have  been  advanced  in  explanation  of  these  deposits. 
We  do  know  that  the  bulk  is  composed  of  calcium  phos- 
phate and  carbonate,  and  that  certain  places  are  more 
liable  than  others  to  the  accumulations.  One  theory  is 
that  the  saliva  holds  these  salts  in  a  very  unstable  sus- 
pension, and,  in  the  presence  of  air,  carbonic  acid  gas  is 
liberated  and  the  calcium  salt  precipitated. 

Burchard  claimed  that  the  saliva,  as  manufactured 
by  the  glands,  is  of  alkaline  reaction,  holding  in  solution 
the  salts  of  calcium.  His  theory  was  that  in  most  mouths 
the  reaction  is  acid,  the  coming  together  of  these  two 
opposite  chemical  compositions  results  in  a  precipitation 
which  is  insoluble  in  the  acid  medium. 

A  third  theory  is  one  of  crystallization.  Younger 
holds  the  view  that  some  bacteria  form  a  nucleus  or 
nidus  about  which  layer  after  layer  of  these  salts  are 
precipitated ;  especially .  does  he  believe  this  to  be  the 
cause  of  the  formation  of  serumal  calculus,  the  idea  being 
that  it  was  just  the  same  as  the  crystallization  of  syrup 
starting  around  a  thread.  These  theories  seem  to  have 
resulted  from  the  observation  that  calculus  formation  in 
other  parts  of  the  body  generally  contains  a  lump  of 
bacteria  around  which  they  have  been  formed. 

The  fourth  hypothesis  is  that  the  calcium  salts  are 
held  in  suspension,  and  when  the  saliva  stagnates,  the 
heavier  substances  collect  in  favored  situations, 

KINDS  OF  CALCULI  AND  DEPOSITS, 

There  are  i)robably  many  variations  in  the  character 
of  the  deposits  on  teeth,  but  the  most  important  from  a 
pyorrhea  standpoint  are  as  follows: 


Calculi  iisr  Pyokrhea  Alveolaris.  219 

1st,  (Tranular  mass,  less  hard  than  calcium  sulphate. 
This  is  generally  found  in  large  quantities  on  the  lingual 
sides  of  inferior  incisors  and  on  the  buccal  surfaces  of 
the  upjjcr  molars. 

'2d,  Concretions  found  below  the  gum  margin;  color, 
light  yellow  to  dark  green.  The  light  concretion  is  soft 
while  the  dark  one  is  hard.  Some  have  thought  that  the 
greeuish  scales  around  the  margin  of  the  gums  might  be 
caused  by  the  disturbance  of  the  gingival  glands.  Pat- 
terson says,  ''These  deposits  are  from  purulent  matter 
;!iid  are  the  sequence  of  irritation  and  inflammation  from 
the  various  local  causes  referred  to.  They  are  not  pre- 
cedent to  a  lesion  but  invariably  are  subsequent  to  irrita- 
tion and  exudation." 

3d,  Serumal  calculus. 

4th,  Sorcles  is  a  soft,  creamy,  pearl  gray  deposit  on 
the  surface  of  the  teeth  and  differs  from  tartar  in  that 
it  does  not  concrete,  though  it  is  sometimes  mixed  with  a 
form  of  tartar  and  partially  concreted. 

We  think  the  reason  for  the  salivary  calculus  deposi- 
ted on  the  upper  molars  being  softer  than  in  other  loca- 
tions is  that  the  parotid  gland  does  not  secrete  mucin. 

The  red  or  greenish  color  of  the  second  varietj^  named 
is  given  by  the  escape  of  heamatin  of  red  blood  corpuscles 
due  to  the  rupture  of  small  blood  vessels  by  mechanical 
irritation  of  the  deposit.  The  extreme  hardness  and 
brittleness  which  we  often  find  is  probably  due  to  the 
absorption  of  uric  acid  fi'om  the  blood.  It  is  supposed 
that  this  occurs  only  with  those  patients  whose  system 
contains  a  large  amount  of  uric  acid.  From  this  observa- 
tion imany  dentists  at  one  time  believed  that  the  whole 
cause  of  jiyorrhea  could  be  explained  by  the  theory  of 
the  uric  acid  diathesis;  but  this  theory  of  its  etiology 
has  been  discarded  l)y  the  majority  of  the  dental  and 
medical  i)rofession. 

The  third  variety  of  calculus  was  first  called  serumal 
by  Brown,  of  Georgia.     This  secretion  and  concreting 


220  Peactical.  Pyokrhea  Alveolaeis. 

material  is  supposed  to  be  formed  from  some  break  in 
the  peridental  membrane  and  effusion  of  the  serum  of 
tlie  blood.  If  this  theory  is  correct  the  process  has  never 
been  successfully  explained. 

At  the  point  of  location  of  the  other  varieties  of  tartar 
we  have  direct  contact  with  the  saliva,  but  with  the 
serumal  calculus  it  is  claimed  that  the  formation  may 
take  place  in  the  peridental  membrane  without  any  show 
of  external  communication  with  the  saliva  of  the  mouth. 
The  very  existence  of  such  a  formation  has  been  denied 
by  many,  who  claim  that  when  calculus:  is  found  on  a 
tooth  there  is  always  some  external  opening  which  can 
be  found  by  careful  probing  with  a  small  instrument 
under  the  cervical  edge  of  the  gum.  Nash  advanced  some 
strong  arguments  on  the  impossibility  of  the  formation 
of  serumal  calculus  or  tophus  in  the  peridental  mem- 
brane. 

black's  theoey. 

Dr.  G.  V.  Black  has  recently  reported  some  interesting 
experiments  about  the  formation  of  tartar.  His  theory 
is'  that  the  susceptible  mouth  contains  a  material  which 
he  tenns  the  ''aglutinating  substance."  This  substance 
is  transparent  and  slightly  sticky.  This  serves  to  gather 
and  hold  particles  of  calcium  salts  w^hicli  are  precipitated 
from  the  saliva.  This  gradually  hardens  after  a  few 
days'.  In  his  personal  experiment  with  a  slot  cut  in  his 
artificial  set  of  teeth  he  advances  the  idea  that  salivary 
calculus  may  be  controlled  to  a  certain  extent  by  the 
diet.  Eating  too  much  caused  him  to  have  a  greater  de- 
posit, while  the  use  of  a  saline  cathartic  would  cause  a 
cessation  of  deposits  for  a  week  or  more. 

Before  the  advent  of  prophylaxis,  dentists  were  pay- 
ing most  of  their  respects'  to  the  hard  deposits  as  the 
principal  factor  in  dental  lesions  but  recently  we  believe 
this  to  be  a  inistaken  idea,  aiid  tliat  the  soft  deposits  are 
more  vicious  in  their  action  on  the  soft  tissues.    In  fact, 


Black's  Theory  of  Calculus.  221 

iipou  the  removal  of  largo  quantities  of  tartar  from  the 
teeth,  we  frequently  find  the  toofh  in  a  well  preserved 
state,  and  the  gums  comparatively  healthy,  but  we  never 
find  this  to  be  the  case  when  the  sordes  or  soft  deposits 
are  removed,  because  the  latter  contain  a  great  amount 
of  infection;  we  sometimes  find  the  tooth  in  a  leathery 
condition  and  the  soft  tissues  always  in  a  state  of  inflam- 
im.ation. 


CHAPTEE     XXIII. 
PATHOLOGY  OF  PYORRHEA  ALVEOLARIS. 

EECESSION  AND  CONGESTION  OF  THE  GUMS. — THE  CHANGES  IN 

THE   PERIDENTAL    MEMBEANE    AND   ALVEOLAR    PROCESS. 

TOOTH      ROOT      ABSORPTION. FORMATION       OF      PUS 

AND  POCKETS. ALVEOLAR  ABSCESS  IN  PYORRHEA. 

The  pathology  of  dentistry  should  be  considered  in  the 
same  manner  as  the  pathology  of  medicine  and  surgical 
diseases.  In  dentistry  the  attempt  to  bring  up  a  differ- 
ent pathology  has  been  due  to  a  lack  of  proper  knowledge 
and  observation. 

In  taking  up  the  work  of  pyorrhea,  the  dentist  must 
have  an  accurate  knowledge  of  normal  conditions  in 
order  to  be  able  to  detect  a  deviation  therefrom.  Also, 
a  complete  knowledge  of  the  histology  of  the  gums,  teeth, 
and  maxilla  is  imperative. 

First  should  be  noted  the  appearance  and  color  of  the 
normal  gum.  We  will  note  that  there  is  no  tumefaction 
of  the  gum  margin;  also  that  the  gum  margin  clings  to 
the  teeth  at  the  enamel  margin,  completely  surrounding 
the  tooth  at  the  insertion  into  the  bone. 

The  teeth  most  often  affected  by  pyorrhea  seem  to 
be  the  lower  incisors.  Next  in  the  order  of  frequency, 
the  superior  molars  and  bicuspids ;  then  the  inferior 
molars  and  bicuspids;  the  superior  incisors;  lastly,  the 
upper  cuspids. 

RECESSION   AND   CONGESTION   OF  THE  GUMS. 

Recession  of  the  gums  is  not  necessarily  a  feature  of 
the  pathology  of  pyorrhea,  although  some  medical  men 
and  many  of  the  laity  have  at  times  mistaken  the  reces- 


Pathology  of  Pyoerhea  Alveolaeis.  223 

sion  of  the  gums,  especially  on  the  upper  cuspids,  for 
pyorrhea.  This  recession  is  the  result  of  not  receiving 
circulation  to  keep  up  peridental  life  and  a  constant 
diminution  of  the  thickness  of  the  alveolus  and  the  hard- 
ness of  the  C0m,entum.  This  structure  either  moulds  into 
the  dentine  or  recedes  towards  the  root  when  conditions 
are  abnormal. 

The  recession  of  the  gums  at  the  cervical  margin 
brings  most  patients  to  the  dentist  for  the  treatment  of 
pyorrhea.  At  this  stage  we  find  the  peridental  membrane 
either  exposed  or  destroyed  in  part,  forming  a  hot  bed 
for  the  culture  of  bacteria  which  continue  their  action  in 
destroying  the  alveolus  and  inflaming  the  periosteum. 
This  recession  is  caused  by  the  falling  in,  as  it  were,  of 
the  supporting  structures. 

Although  the  patient  worries  about  the  gums,  it  is 
oftentimes  the  least  affected  structure  and,  if  the  infec- 
tion be  removed,  soon  resumes  its  normal  appearance 
and  function  as  a  protection  to  the  structures  which 
underlie  it.  Just  as  often  do  w^e  find  the  opposite  picture. 
Instead  of  recession  we  find  a  swelling  and  congestion. 
On  squeezing  the  gums,  pus  will  generally  exude.  On  the 
other  hand,  I  have  seen  cases  where  there  seems  to  be  no 
pus ;  but  there  is  infection,  and  pus  either  has  been  or  will 
be  the  next  step  in  the  progress  of  the  disease. 

Probably  one  of  the  most  constant  diagnostic  points 
in  pyorrhea  is  the  tumefaction  of  the  gum  tissues.  The 
extent  of  this  tumefaction  may  be  from  a  few  lines  in 
width  at  the  gum  margin  to  a  heavy  roll  of  tissue  extend- 
ing the  full  breadth  of  the  roots  of  the  teeth.  This  tume- 
factory  condition  may  be  hard  and  firm,  and  when  this 
is  the  case,  the  color  of  the  tissue  will  be  a  light  lilac  or, 
if  the  pocket  beneath  be  extensive,  of  purplish  tint.  How- 
ever, this  tissue  may  present  a  very  different  clinical 
picture  in  that  the  tissue  may  be  very  soft  and  fluffy, 
bleeding  upon  slight  irritation,  as  in  brushing  the  teeth. 


224  Peactical,  Pyokkhea  Alveolaris. 

In  tlie  latter  condition  we  find  more  pus,  we  also  find  that 
the  teeth  are  looser  than  in  the  former  condition  de- 
scribed. 

Often  the  gum  is  filled  with  inflammatory  exudate, 
giving  a  rich  crimson  (chronic  state  bluish)  color,  due 
to  the  accumulation  of  cells  in  the  connective  tissue. 

This  gum  bleeds  at  the  slightest  touch.  Inflamma- 
tion may  extend  only  to  periosteum  or  into  the  alveolus. 
If  the  condition  of  swelling  continues  and  the  gum  con- 
tinues flabby  about  the  tooth,  like  hypertrophied  tissue, 
the  best  treatment  is  the  surgical  trimming  with  knife 
or  scissors. 

When  the  patients  are  about  to  be  dismissed  after 
treatment,  they  often  call  attention  to  the  fact  that  their 
gums  have  receded  more  than  they  did  previous  to  treat- 
ment. This  seems  to  them  a  most  serious  question,  and 
the  dentist  should  be  very  careful  to  convince  the  patients 
that  such  recession  always  follows  a  correct  treatment, 
because  of  a  reduction  of  the  inflammation  and  a  return 
of  the  gum  to  its  natural  thickness.  In  addition  to  this, 
the  alveolus  surrounding  the  teeth  is  now  much  less  than 
before  disease,  or,  having  been  removed  in  the  surgical 
work,  gives  the  gum  covering  it  the  opportunity  to  fall 
further  away  from  the  crown  of  the  tooth. 

This  recession,  if  extensive,  may,  in  the  future,  cause 
trouble  for  the  reason  that  the  flap  of  gum  tissue  which 
normally  protected  the  interproximal  space  from  food 
impactions  may  be  too  low  to  protect  this  space  against 
further  inflammation  and  infection  from  packing.  It 
must  be  well  understood  that  in  these  cases  the  patient 
should  present  at  frequent  intervals  and  have  such  spaces 
cleaned  by  their  dentist. 

THE  PERIDENTAL  MEMBRANE. 

The  object  of  the  peridental  membrane  is'  to  transmit 
nourishment  to  the  teeth  and  to  furnish  elacticity  and  a 
cushion  under  force,  or  a  sling  in  which  the  teeth  are 
held. 


Pathology  of  Pyoeehea  Alveolaeis.  225 

Dentists  have  been  taught  that  the  peridental  mem- 
brane partook  more  of  the  character  of  a  periosteum,  but 
later  investigators  claim  this  structure  to  be  a  true 
alveolar-dental  ligament.  Microscopical  examination 
reveals  solid  bundles  of  fibres  of  Sharpey  which  extend 
from  the  tooth  out  into  the  alveolar  process.  The  in- 
sertion is'  about  the  same  as  ligamentous  insertion  into 
bone  in  other  parts  of  the  body.  These  fibres  of  Sharpey, 
according  to  several  authorities,  form  circular  rings 
which  suspend  the  tooth  in  its  socket. 

The  peridental  membrane  has  for  one  of  its  purposes 
the  nutrition  of  the  cementum.  This  membrane  may  be 
separated  from  the  tooth  or  completely  absorbed  at  the 
time  of  the  first  injury,  be  it  tartar,  bad  dentistry  or 
infection. 

Healthy  strong  teeth  are  often  exfoliated  from  the 
alveolus  because  of  hypernutrition,  which  results  in  de- 
posits in  the  substance  of  this  membrane  making  it  re- 
semble the  cementum,  or  the  membrane  may  be  so  feeble 
in  its  function  as  to  shut  off  nutrition  with  like  result. 
Cases  of  loose  teeth  from  this  cause  have  frequently  been 
diagnosed  pyorrhea. 

We  must  bear  in  mind  that  an  edentulous  jaw  never 
presents  a  pyorrheal  condition,  and  that  the  extraction 
of  the  affected  tooth  or  teeth  affords  relief  for  that  part 
of  the  bone.  This  is  even  so  when  the  process  has  be- 
come carious  in  the  advanced  stages.  This  leads'  us  to 
believe  that  the  pathological  condition  is  centered  around 
the  tooth  root  and  its  attachment  to  the  bone. 

Smith  has  called  our  attention  to  the  diagnostic  points 
in  differentiating  pericemental  abscess  and  pyorrhea. 

Pericemental  abscess  is  not  the  result  of  putrescent 
pulp  tissue,  but  on  the  contrary,  it  generality  occurs  on 
live  teeth  between  the  bification  or  at  the  end  of  fused 
roots.  The  pain  is  not  severe  but  continuous.  There  are 
no  inflammatory  symptoms.  The  discharge  of  pus  is 
small,  oozing  to  the  surface  of  the  gum  margin:  it  never 


226  Peactical  Pyokkhea  Alveolaeis. 

forms  fistulae  like  a  pulp  abscess.  On  extraction  these 
teeth  present  small  globules  of  pus  having  no  confining 
Qiembrane. 

The  constitutional  symptoms  are  very  severe  as  com- 
pared with  the  severity  of  the  pathological  condition. 
Nervous  oppression,  indigestion,  malaise  or  headache 
may  result  from  the  absorption  of  pus  from  these  ab- 
scesses. 

Smith  claims  that  pericemental  abscess  is'  not  a  state 
of  pyorrhea,  although  they  are  often  associated  in  the 
same  mouth.  The  abscess'  develops  in  some  inaccessible 
depression  between  bicuspids  or  molars',  while  pyorrhea 
is  found  on  straight  rooted  teeth.  Smith  further  claims 
that  teeth  affected  with  abscess  cannot  be  cured  except 
by  extraction. 

The  soreness,  looseness  and  pus  discharge  from  this' 
class  of  teeth  is  often  mistaken  for  pyorrhea,  and  conse- 
quently unsuccessfully  treated. 

ALVEOLAR   PEOCESS. 

Tolbot  in  his  well  defined  theory  would  have  us  be- 
lieve that  the  alveolar  process  is  of  a  diiferent  structure 
from  the  rest  of  the  maxilla,  and  that  it  is  a  transitory 
structure  whose  only  purpose  is  to  mould  itself  about  the 
teeth,  and,  when  they  are  lost,  to  be  absorbed.  His  ex- 
periments and  arguments  have  been  largely  accepted  by 
the  dental  profession.  The  author  is  of  the  opinion  that 
tbe  alveolar  process  is  in  no  way  different  in  its  charac- 
teristics and  structure  from  the  rest  of  the  bone,  and  that 
the  socket  is  simply  a  medullary  space,  situated  in  an 
extension  of  the  maxilla. 

If  the  initial  infection  is  not  removed,  the  part  fol- 
lows the  usual  course  of  infection  and  inflammation.  As 
this  condition  progresses,  the  tartar  and  infection  con- 
tinues to  collect  on  the  teeth  and  gums  until  it  results  in 
alveolar  pyorrhea  and  we  have  pus  pockets.  ISTow  in  the 
event  this  infection  is  not  removed,  the  bone  begins  to 


Pathology  of  Pyorehea  Alveolaeis.  227 

liquify,   constituting   alveolar   necrosis,   and  finally   tlie 
teeth,  lose  tlieir  attachment  and  become  exfoliated. 

In  the  true  sense  of  the  word  necrosis,  from  a  medical 
standpoint,  cannot  properly  be  applied  to  the  molecular 
disintegration  of  the  alveolus  in  pyorrhea.  Certainly,  we 
do  not  have  any  considerable  bone  dying  in  masses,  thus 
the  process  is  more  of  the  character  of  carious  bone. 
However,  necrosis  is  in  common  usage  among  dentists  in^ 
describing  this  condition. 

TOOTH    EOOT    ABSOEPTION. 

Often  on  failure  to  restore  a  tooth  by  treatment,  we 
extract  it  and  find  the  end  absorbed,  leaving  a  rough 
margin  with  small  sharp  projections. 

On  Sept.  2,  1913,  I  wrote  to  Dr.  J.  B.  Hartzell  asking 
him  to  answer  the  following  questions  relative  to  the 
absorption  at  the  end  of  the  roots  of  teeth,  especially 
with  respect  to  the  lower  central  and  lateral  incisors : 

1st,  Why  is  it  that  these  teeth  are  m.ore  prone  to  root 
absorption  than  other  teeth  f 

2d,  How  does  it  occur  and  leave  the  teeth  alive  ? 

3d,  Is  it  the  same  x^rocess  that  occurs  with  the  tem- 
porary teeth? 

4tli,  Is  there  any  way  of  diagnosing  probable  root 
absorption  before  it  takes  place  ? 

In  answer  to  these  questions  Dr.  Hartzell  wrote  me 
as  follows : 

"The  process  of  root  absorption  in  teeth  that  have 
l(xst  bony  support  is  largely  due  to  movement,  which  stim- 
ulates osteoclasis.  My  experience  with  those  teeth  is 
that  the  more  rigid  they  are  held  in  position,  the  less 
root  absorption.  Of  course  there  is  a  certain  amount  of 
irritation  from  bacterial  poison  in  all  cases,  which  added 
to  the  physical  movement,  further  stimultes  bone  de- 
struction by  making  perfect  the  conditions  for  absorption. 

"Did  you  ever  see  the  two  ends  of  a  broken  bone  in 
which  you  had  a  false  joint  finally  established  ?    The  ends 


228  Peactical  Pyoeehea  Alveolaeis. 

of  such  bones  are  roiiiided  and  resorbed  back.  This  is 
the  same  thing  which  occurs  in  the  socket  about  the  end 
of  a  tooth  that  has  movement,  and  also  is  the  same  pro- 
cess which  destroys  the  root  end. 

"No,  it  is  not  the  same  process  that  occurs  with  the 
temporary  teeth.  That  is  a  normal  physical  condition, 
and  the  process'  is  stimulated  in  the  case  of  temporary 
teeth  through  the  irritation  by  the  uplift  of  the  perma- 
nent teeth  against  the  deciduous  root  end,  and  happens 
long  before  any  movement  can  occur  in  the  tooth  by 
reason  of  its  shortened. root  and  without  infection. 

''Yes,  root  absorption  is  always  probable  where  there 
is  considerable  movement  established  or  where  infections 
are  resident  in  the  tissues  around  the  root  end." 

Dr.  Hartzell  did  not  answer  the  second  question,  nor 
has  anyone  else,  to  my  satisfaction.  Tlie  answer  to  the 
fourth  can  be  deducted  from  his  remarks.  Stop  move- 
ment by  treatment  and  splint. 

FOEMATIOIiT  OF  PUS  AND  POCKETS. 

The  result  of  irritation  to  the  gingival  tissues  pro- 
duces an  exudate.  This  exudate  becomes  septic  through 
the  action  of  the  bacteria  of  the  mouth,  forming  pus ;  sup- 
puration destroys  the  adjacent  alveolus,  forming  the  so 
called  ''pockets." 

In  the  early  stages,  the  extent  or  depth  of  a  pocket 
on  the  tooth  root  is  indicated  by  a  reddish  area.  As  the 
disease  progresses  and  becomes'  chronic  the  color  changes 
to  a  purplish  hue.  The  color  of  the  pus  from  the  red- 
dish area  is  yellow;  that  from  the  chronic  or  old  standing 
is  mixed  with  stagnant  blood  and  is  dark  blue,  purplish 
or  black  in  color. 

ALVKOTAR   ABSCESS   IN"   PYOEEHEA. 

A  narrow  constricted  pocket  may  become  suddenly 
very  active  or  the  exit  from  any  pocket  may  become 
blocked    to    Foitn    a    pyorrheal    alveolar    abscess.      The 


Pathology  op  Pyoeehea  Alveolaeis. 


229 


swelling  may  have  some  of  the  aiDpearances  of  the  ordi- 
nary alveolar  abscess  from  a  decomposed  pnlp,  and  is 
often  mistaken  for  such. 

Differential    diagnosis    between    pulp    alveolar    and 
pyorrheal  alveolar  abscess : 


PULP  ABSCESS. 

Only  on  dead  teeth 
Comes  on  g-radually 
Severe  throbbing  pains 
Swelling  extends  over  consider- 
able area 
Color,  bright  red 
Location,  near  root  ends 


PYOKRHEAL     ABSCESS. 

Generally  on  live  teeth 
Appears  in  a  few  hoiu's 
Pain  not  so  severe 
Swelling  localized   on   one  tooth 

Color,  generally  purple 
Location,    near   cervical   border    of 
glims. 


Other  points  connected  with  the  pathological  anatomy 
are  intimately  associated  with  and  described  under  the 
following  pages. 


CHAPTER     XXIV. 

SYMPTOMS/DURATION,  DIAGNOSIS  OF 
PYORRHEA. 

SYMPTOMS. 

As  we  said  in  the  definition  of  pyorrhea,  it  is  of  slow 
onset.  So  slow  is  it  that  a  patient  may  have  it  for  years 
and  be  unaware  of  his  condition  until  a  dentist  tells  him 
of  it.  On  the  other  hand,  it  is  a  sleeping  volcano,  liable 
to  break  out  at  any  time.  Suddenly,  some  day  the  gums 
begin  to  swell  and  the  volcano  breaks  forth  with  an 
alveolar  abscess.  You  will  find  that  in  the  incipient  stage 
the  patient  stops  brushing  his  teeth  because  the  gums  are 
painful  and  bleed.  In  the  latter  stages  you  will  find  the 
exudation  of  pus,  and  the  teeth  becoming  loose. 

The  symptoms  are  sometimes  so  mild  that  it  is  diffi- 
cult to  diagnose  the  condition  until  you  have  made  a 
thorough  examination.  A  physician  once  referred  a  case 
of  pyorrhea  to  me  and  I  reported  that  I  did  not  think  the 
case  serious.  I  failed  to  make  the  proper  examination. 
When  I  operated,  I  found  the  condition  serious  in  that 
the  alveolus  was  almost  disintegrated. 

To  know  the  early  signs  of  the  disease  one  must  be 
very  familiar  with  them  and  always  make  a  careful 
probing  examination.  The  patient  may  have  had 
pyorrhea  before  he  got  into  the  habit  of  brushing  his 
teetli,  so  that  when  he  comes  to  you  his  teeth  may  be  in 
a  clean  condition,  thus  somewhat  covering  up  the  septic 
picture  and  deceiving  the  examiner. 

A  rather  common  syiny)tom  of  advanced  pyorrhea  is 
a  separation  ol'  tlie  tcctli,  destroying  the  contact  points 
and  giving  entrance  for  food  impaction.  The  peculiarity 
of  this  separation  is  that  the  affected  tooth  bears  away 
from  the  point  of  infection  or  pocket.    At  first  glance  it 


Symptoms  of  Pyoerhea  Alveolaris.  231 

would  seem  that  the  tooth  would  fall  over  on  the  weaken- 
ed side.  If  we  imagine  the  tooth  to  have  rubber  bands 
on  both  sides,  each  pulling  the  tooth  in" the  opposite  direc- 
tion, should  one  be  cut,  we  know  that  the  tendency  of 
the  tooth  would  be  to  move  toward  the  side  where  the 
rubber  remained.  Now  the  peridental  membrane  or 
ligamentous  fibres  are  the  elastic  bands  which  draw  the 
tooth  away  from  the  side  where  pyorrhea,  has  weakened 
the  "sling." 

Mal-occlusion  is'  almost  a  constant  symptom  and  re- 
sult of  oral  sepsis.  It  seems  that  the  teeth  are  constantly 
changing  their  position  in  pyorrhea.  One  patient  had  a 
lower  cuspid  which  had  turned  half  way  around.  An- 
other patient  had  such  a  wide  separation  between  the 
two  lower  centrals  that  a  bridge  with  two  extra  teeth 
was  required  to  fill  the  gap.  The  result  in  such  cases  is 
to  destroy  the  proper  occlusion. 

One  of  the  most  constant  sj^mptoms  of  pyorrhea  is 
the  odor  coming  from  the  pus,  which  is  similar  to  that 
from  a  diseased  antrum.  You  instantly  detect  this  odor 
as  soon  as  the  patient  opens  his  mouth,  and  you  will 
soon  learn  to  know  it.     The  odor  is  characteristic. 

The  patients  will  nearly  always  tell  you  that  they 
brush  their  teeth  from  two  to  six  times  per  day,  and  that 
they  cannot  understand  why  their  gums  should  give  them 
any  trouble. 

The  slight  general  symptoms  are  not  nearly  what  we 
might  expect  from  such  an  amount  of  infection;  we  are 
surprised  to  have  some  of  the  patients  state  that  they 
suffer  no  other  than  local  mouth  symptoms.  In  other 
eases  they  have  attacks  of  indigestion  and  have  probably 
been  treated  by  a  stomach  specialist. 

The  patient  may  exhibit  the  symptoms  of  various 
other  diseases  connected  with  the  eye,  throat,  heart  or 
kidney  which  may  be  traced  to  mouth  infection  from 
pyorrhea. 


232  Practical  Pyorrhea  Alveolaris. 

duration. 

The  duration  of  pyorrEea  is  very  uncertain.  The 
incipient  form,  so  called  gingivitis,  may  run  along  many 
years  before  developing  into  the  more  severe  types. 
Wlien  an  infection  of  long  standing  does  begin  to  make 
inroads  into  deeper  structure,  the  progress  of  the  disease 
is  very  rapid.  There  are  many  factors  as  to  health,  local 
mouth  conditions  and  character  of  infection  or  inflamma- 
tion which  affect  the  duration. 

Individuals  who  have  healthy  mouths  and  who  ordi- 
narily give  proper  regard  to  dental  toilet  may  for  some 
cause,  such  as  sickness  or  severe  grief,  entirely  omit  any 
care  of  their  mouths.  This  lowering  of  vital  resistance 
together  with  the  omission  of  cleaning  the  mouth  will 
produce  a  pyorrheal  condition  giving  a  history  of  rapid 
development.  In  so  short  a  time  as  thirty  days  such  a 
case  may  exhibit  bleeding  gums',  pus,  and  loosened  teeth. 

A  recent  case  was  that  of  a  young,  healthy  girl  of 
sixteen  years  who,  inside  of  six  months,  developed  such 
a  severe  pyorrhea  that  one  tooth  dropped  out  into  the 
spittoon  while  making  the  examination.  It  would  have 
been  a  safe  guess  to  say  that  in  six  months  more  she 
would  have  lost  many  of  her  teeth.  This'  case  yielded 
promptly  to  treatment  with  the  exception  of  lower  central 
and  lateral,  which  were  bridged. 

On  the  other  hand,  just  the  opposite  history  of  dura- 
tion is  often  met  with.  Patients  often  answer  that  they 
have  had  diseased  gums  from  ten  to  twenty  years. 

From  these  observations  it  will  be  seen  that  there  is 
no  regTilar  rule  as  to  the  time  required  for  pyorrhea  to 
run  its  course  to  the  stage  where  there  is  exfoliation  of 
the  affected  teeth.  This  much  we  do  know ;  it  never  gets 
better  spontaneously  without  treatment,  but  always, 
whether  gradually  or  rapidly,  is  sure  to  continue  to  grow 
worse. 


Diagnosis  of  Pyorrhea  Alveolaris.  233 

diagnosis, 

Dr.  Youiiger  has  written  that  "fully  ninety-five  per 
cent  of  the  Anglo-Saxon  race  have  pyorrhea  in  some 
stage  of  development  in  one  or  more  of  the  alveoli.  It 
is  common  among  all  races  in  all  countries,  and  among 
all  classes.  The  rich  and  the  poor,  the  well  conditioned 
and  the  mean,  the  vegetarian  and  the  meat  eater,  the 
bibulous  and  the  abstemious,  the  fat  and  the  lean,  the 
robust  and  the  debilitated,  the  strong  and  the  weak  are 
all  affected.  Neither  does  temperament  seem  to  produce 
immunity,  for  the  nervous,  the  sanguine,  and  the  phleg- 
matic suffer  from  it." 

I  am  sorry  to  say  that  even  though  the  proportion  is 
large  many  dentists  who  are  accustomed  to  making 
diagnoses  of  carious  conditions'  are  not  able  to  diagnose 
a  pyorrhea  case.  Patients  often  complain  that  the  den- 
tist did  not  tell  them  that  they  had  pyorrhea.  Some  den- 
tists may  at  times  recognize  the  condition  but  not  attend 
to  it.  In  other  cases  the  disease  has  not  received  the 
]3roper  treatment,  meanwhile  growing  worse,  and  valu- 
able time  is  lost  before  the  patient  is  finally  referred  to 
a  dentist  or  specialist  who  can  cure  pyorrhea. 

The  time  is  passing  when  a  well  informed  dentist  will 
limit  his  diagnosis  of  pyorrhea  to  what  he  sees  in  the 
mouth.  Dr.  Arthur  H.  Merritt  wrote  me  recently  that 
he  believes  ''still  more  attention  should  be  paid  to  the 
general  health  of  ])atients,  and  very  careful  histories 
made,  such  as  urinary  analysis',  blood  counts,  (including 
a  differential),  blood  pressure,  Wasserman  test,  when 
syphilis  is  suspected,  radiographs,  etc.  Constipation 
seems  to  be  associated  with  bad  pyorrhea  conditions  and 
should  be  looked  for  and  corrected." 

Often  grave  responsibility  is  attached  to  our  diag- 
nosis. For  instance,  xVnglii  calls  attention  to  cases  of 
ulcerative  gingivi-stomatitis  due  to  Vincent's  bacteria. 
These  cases  are  said  to  have  a  close  resemblance  to  diph- 
theria, wliile  the  nioutli  complication  may  be  pyorrhea. 


234  Peactical  Pyokrhea  Alveolaris. 

This  infection  is  found  between  the  teeth  or  in  inacces- 
sible places.  The  interproximal  gum  tissue  and  alveolus 
undergo  a  quick  necrotic  destruction.  The  diagnostic 
points  are :  the  gray  color  which  when  rubbed  otf  leaves 
a  bleeding  surface  which  will  reproduce  within  two  hours, 
much  pain  and  loss  of  gum,  festoon.  Positive  diagnosis 
must  be  made  by  microscopical  examination. 

Some  other  conditions  with  which  we  should  be  famil- 
iar in  making  a  diagnosis  are  syphilis,  leucoplakia  and 
tuberculosis.  I  will  not  go  into  a  detailed  description  of 
these  diseases;  but  just  a  point  or  two  is'  given  bearing 
on  the  diagnosis  from  pyorrhea.  The  initial  lesion  of 
syphilis  produces  a  round  oval  nodule  on  lip  or  tongue 
which  in  color  resembles  that  of  boiled  ham.  The  size 
may  vary  from  that  of  a  large  pin  head  to  a  ten  cent 
piece.  They  are  always  painless  and  indurated.  In 
syphilis  itself  the  alveolus  may  come  away  as  a  seques- 
trium  because  the  circulation  is  cut  off  to  such  an  extent 
that  the  pulp  and  surrounding  structure  may  die.  In 
diagnosis  we  must  contrast  this  rapid  destruction  with 
the  slow  disintegration  of  the  alveolus  from  the  gingival 
border  towards  the  apex  which  we  find  in  pyorrhea. 

Leucoplakia  is  a  rare  condition,  but  should  be  sus- 
pected if  gums  and  cheeks  present  small,  pale  colored 
patches  which  are  slightly  indurated. 

Tubuculous  conditions  are  likewise  of  rare  occurence 
in  the  mouth.  When  present,  we  have  small  yellow 
granular  nodules  which  are  located  mostly  in  the  pos- 
terior part  of  the  mouth  and  pharynx. 

In  making  a  diagnosis  of  pyorrhea,  we  must  not  only 
know  the  physical  symptoms  but  go  beyond  the  mere 
mouth  conditions.  As  suggested  by  Dr.  Merritt  the  gen- 
eral history  of  the  ]jatient  must  be  taken  into  account 
when  a  diagnosis  is  given.  By  the  routine  use  of  a  his- 
tory chart  many  interesting  and  valuable  facts  for  the 
diagnosis  of  pyorrheal  conditions  are  brought  out  which 
will  have  a  bearing-  on  the  treatment. 


Pyoeehea  Alveolaeis  Histoey  Chaet. 


235 


Name  Address   Date 

Examination     1.  No.  of  teeth  involved 2.  No.  of 

teeth  with  deposits  on  enamel  and  no  destruction  of  peridental  fibres 

3.  Teeth  with  pus  discharge 4.  Teeth 

loose  with  no  pus  discharge 5.  Condition  of  teeth 

mucus  membrane ,  bone 

character  of  deposits Occlusion 

Prothesis  worn 

History       6.  Age 7.  Duration 8.  Beginning 

point  of  inflammation  

9.  Most  recent  point  of  inflammation 10.  Habits 

Tobacco Alcohol 

Oral  Hygiene 

11.  Parents'  teeth 

Systematic  Condition  Blood  pressure  

Urinalysis  


Saliva    12.  Have  you  had  any  trouble  with 

your  digestion  °i 

13.  Have  you  had  any  pain  in  your  abdomen  1. 

14.  Which  did  you  notice  first — trouble  in  mouth  or  stomach? 

15.  Have  you  had  any  he.irt-burn  *? 

16.  Do  you  notice  any  excess  of  saliva  after  eating  f 

17.  Have  you  any  tendency  to  Diarrhea  or  Constipation? 

Do  you  use  laxatives'? IS.  Do  you  have  Tonsilitis? 

Rheumatism?  Gout?   Shortness  of  breath 

or  palpitation  on  exertion? 10.  For  what  other 

diseases  have  you  been  treated  ? 

20.  Are  you  under  care  of  physician  at  present  time? 

Prognosis    21.  Grood Fair Doubtful 

Hopeless To  be  extracted 

22.  Prosthesis  indicated    

Treatment  and  Results. 


Fig.  33. 


CHAPTER     XXV. 
PROGNOSIS. 

BLOOD  PEESSURE. AETIFICIAL  TEETH  IN  REGARD  TO  PYORRHEA. 


The  question  that  patients  ask  the  dentist  when 
informed  that  they  have  pyorrhea  are,  ' '  Can  you  cure  it, 
Doctor!    Will  it  stay  cured!    Do  you  guarantee  a  cure?" 

To  the  last  named  question  the  dentist  should  always 
be  prepared  with  an  answer  and,  though  he  might  gain 
a  little  more  business  by  saying  that  he  could  guarantee 
a  cure,  still  the  time  may  come  around  when  he  will 
regret  having  told  the  patient  this.  One  dissatisfied 
patient  can  do  a  dentist  a  great  deal  of  harm.  He  should 
be  told  that  to  ''guarantee"  is  only  to  make  use  of  a  catch 
phrase  used  by  dental  parlors  and  shyster  physicians. 
Patients  would  not  think  of  asking  a  physician  to 
guarantee  a  cure  of  typhoid  fever  or  grippe  or  ear 
trouble,  before  accepting  his  services.  The  patient  with 
pyorrhea  must  understand  that  there  are  so  many  con- 
ditions on  which  our  success  depends  that  a  cure  cannot 
be  guaranteed.  Then  again,  we  are  not  in  the  insurance 
business.  Nature  could  not  make  teeth  with  a  guarantee 
that  they  would  stand,  certainly  we  should  not  be  ex- 
jjected  to.  The  way  to  get  out  of  all  arguments  of  this 
question  is  the  method  I  use  in  my  office.  On  the  exami- 
nation sheet,  I  have  x)i'inted  at  the  bottom  the  informa- 
tion that  "we  do  not  guarantee  any  operations."  The 
patient  at  once  sees  this  and  all  questions  along  this'  line 
are  generally  avoided. 

To  the  query,  ''Will  it  stay  cured!"  we  can  answer  a 
little  more  definitely.  If  we  have  diagnosed  the  case 
])roperly,  and  have  ])romised  a  cure,  we  can  tell  them 
with  some  degree  of  certainty  that  where  the  proper  de- 
gree of  oral  hygiene  is  carried  out,  and  where  repeated 


Peognosis  of  Pyorrhea  Alveolakis.  237 

visits  at  stated  intervals  are  made  to  the  dentist,  for  the 
purpose  of  having  the  teeth  cleaned  and  polished  (system- 
atic prophylaxis)  that  thej^  should  not  only  stay  cured  but 
that  the  condition  of  their  mouths  should  improve  with 
every  visit  to  the  dentist.  In  other  words,  if  the  opera- 
tion is  successful,  and  the  patient  masters  the  proper 
technique  of  keeping  the  teeth  and  gums  in  good  con- 
dition, the  mouth  conditions  should  improve  all  the  time. 

The  question  as  to  the  curability  of  pyorrhea  is  one 
which  has  been  freely  discussed  by  dentists,  and  on  it  lias 
hinged  much  of  the  criticism  of  experts  and  specialists 
in  pj^orrhea.  If  you  mean  by  "cure"  that  the  bony 
structure  will  rebuild  and  will  be  restored  to  its  normal 
bulk  around  the  teeth;  if  you  mean  that  the  gums  will 
grow  back  to  their  normal  position  at  the  juncture  of  the 
enamel  and  root  of  the  teeth  and  with  the  same  degree  of 
firmness  as  heretofore;  if  you  mean  that  the  patients 
will  be  able  to  go  as  other  people  with  just  ordinary 
care  of  their  mouths,  then  we  would  have  to  admit  that  a 
real  case  of  pyorrhea  alveolaris  is  never  cured.  Of 
course,  in  mild  and  incipient  cases  of  pyorrhea,  all  this 
does  not  appl}^,  but  we  are  referring  to  the  more  advanced 
case.  Remember,  in  giving  your  prognosis,  that  the 
patient  expects  the  gum  tissue  to  grow  up  to  its  original 
position  at  the  juncture  of  the  enamel  and  the  dentine, 
therefore  it  should  be  explained  that  the  gums  will  prob- 
ably shrink  from  the  teeth  even  more,  for  this  is  one  re- 
sult of  a  successful  pyorrhea  operation  in  that  tumefac- 
tion is  reduced. 

In  answer  to  a  question  about  the  cure  of  alveolar 
pyorrhea  Dr.  Arthur  E.  Peck,  of  Minneapolis,  wi'ites : 

"The  burden  of  maintaining  a  cure  after  tlie  treat- 
ment of  pyorrhea  rests  largely  with  the  dentist.  You 
must  impress  upon  your  patients  the  necessity  of  having 
their  teeth  looked  over  at  certain  intervals,  notifying 
them  when  they  should  call  for  a  prophylactic  treatment. 
This  treatment  is  one  of  the  most  important   ste]is   in 


238  Practical  Pyorrhea  Alveolaris. 

maintaining  a  permanent  cure  of  pyorrhea.  If  the  first 
treatment  for  this  disease  has  been  thorough  and  the 
removal  of  absolutely  every  particle  of  the  pyorrheal  de- 
posits has'  been  accomplished  the  case  is  then  cured.  But 
in  many  cases  the  return  of  the  disease  can  only  be  pre- 
vented by  the  assistance  of  the  patients  and  at  stipulated 
times  a  prophylactic  treatment  which  requires  as  much 
or  even  more  skill  than  to  treat  the  case  originally.  The 
instrumentation  must  be  thorough  and  every  particle  of 
the  returning  deposits  removed.  It  requires  the  touch 
of  the  skilled  operator  to  detect  these  slight  deposits  but 
this  is  essential  to  a  permanent  cure."  ^ 

The  question  as  to  the  curability  of  a  given  case  is  one 
which  depends  a  good  deal  on  the  individual  skill  of  the 
dentist.  A  case  may  be  incurable  in  the  hands  of  one 
practitioner  and  easily  cured  by  another,  who  is  more 
skillful  in  the  removal  of  pyorrheal  conditions. 

By  proper  treatment,  pyorrheal  conditions  can  be 
healed,  the  tumefaction  of  the  gums  and  soreness  of  the 
teeth  can  be  made  to  disappear.  The  shedding  of  the 
teeth,  flow  of  pus,  elongation  of  the  teeth,  recession  of  the 
gums,  carious  action  in  the  bone  and  its  resulting  odor 
can  be  obliterated.  These  are  the  benefits  to  be  derived 
from  the  treatment  of  diseased  gums.  Not  only  this,  but 
we  can  also  prevent  other  teeth  in  the  same  mouth  from 
becoming  infected. 

In  regard  to  the  curability  of  pyorrhea  Hutchinson 
says: 

''The  great  majority  still  believe  it  to  be  incurable, 
and  progress  is  being  seriously  hampered  by  the  influence 
of  those  who  persistently  refuse  to  believe  what  some  of 
us  know  to  be  true  ....  The  fact  that  the  majority 
have  failed  in  their  efforts  to  cure  pyorrhea  has  had 
greater  weight  than  the  successful  effort  of  the  few  .... 
I  have  frequently  been  told  by  patients  that  some  friend 
of  theirs,  at  their  solicitation,  had  intended  to  have  treat- 
ment for  pyorrhea,  but  had  abandoned  the  idea  because 


Prognosis  of  Pyorrhea  Alveolarts.  239 

tlie  dentist  had  told  tlieiii  that  it  was  a  constitutional 
disease  and  could  not  be  cured.  No  man  has  the  right  to 
dei^rive  the  patients  of  a  benefit  because  he  either  cannot 
render  the  service  or  is  ignorant  of  the  fact  that  it  can 
be  rendered  ....  If  any  practitioner  fails  in  his 
attempts,  he  must  not  conclude  that  a  cure  cannot  be 
effected.  If  he  fails,  there  is  a  good  reason  for  it,  and 
he  may  succeed  later  on." 

The  dental  profession  has  been  responsible  for  the 
loss  of  thousands  of  teeth  just  because  so  many  dentists 
have  told  their  patients  that  there  is  no  cure  for  pyorrhea. 
If  dentists  have  such  large  practices  that  they  do  not 
care  to  take  time  for  the  treatment  of  these  cases,  it  is 
well  for  them  to  know  that  other  men  in  the  profession 
are  making  a  success'  of  this  work  and  that  from  75  to 
85  per  cent,  of  all  cases  of  pyorrhea  are  being  cured  and 
stay  cured  under  the  care  of  these  operations.  I  do  not 
make  this  statement  from  mere  hearsay  nor  from  what 
other  men  have  written.  In  addition  to  my  own  expe- 
rience in  treating  these  cases,  I  have  been  in  the  offices  of 
other  specialists  and  have  seen  numbers  of  patients'  who 
have  been  cured.  This  will  be  discussed  again  at  full 
length;  but  let  no  dentist  be  again  guilty  of  saying  that 
pyorrhea  operations  are  failures,  for  it  is  up  to  us  and 
up  to  the  dental  j^rofession  to  stop  this  horrible  increase 
of  oral  sepsis. 

In  giving  our  prognosis  to  the  patient,  we  should 
bear  in  mind  that  the  disease  in  the  upper  jaw  is  more 
amenable  to  treatment  than  in  the  lower.  In  the  first 
place  the  structure  of  the  teeth  and  jaw  favor  this  and 
they  are  more  easily  operated  on  in  the  immovable  upper 
jaw.  In  addition  to  this,  they  are  not  subjected  to  the 
movement  of  the  muscles  and  are  not  constantly  im- 
mersed in  the  re-infecting  saliva.  On  the  other  hand, 
the  prognosis  should  be  much  more  guarded  if  the 
disease  has  taken  hold  of  the  lower  jaw.  Here  all  tlie 
secretions  are  constantly  coming  into  the  pocket  that 


240  Peactical  Pyoeehea  Alveolaeis. 

we  are  trying  to  heal,  and  it  is  difficult  to  keep  the  medica- 
ments that  we  apply  in  place  for  any  length  of  time  so  as 
to  get  their  full  effect. 

]f  the  patient  can  be  operated  on  before  any  destruc- 
lion  of  the  supporting  tissues',  so  much  the  better,  but  in 
tliosc  cases  where  this  has  occurred  to  au}^  considerable 
extent,  even  though  an  operative  proceedure  might  for 
the  time  being  tighten  these  teeth,  it  would  be  better  to 
extract  them  at  once. 

On  the  question  of  bony  support,  Smith  says: 

' '  The  permanent  tightening  of  teeth  which  have  been 
loosened  from  pyorrhea,  is  wholly  dependent  on  the 
amount  of  support  remaining  in  the  alveolus  and  the  life 
of  the  cementum. 

''If  the  destruction  of  the  pericementum  caused  by 
the  necrotic  wasting  of  the  alveolus  has  not  progressed 
too  far,  the  tissues  about  the  loosening  teeth  may,  by 
intelligent  treatment,  be  made  to  close  in  upon  the  roots 
and  thus  to  a  greater  or  less  degree,  they  will  tighten  in 
their  sockets. 

"Terminal  alveolar  tissue  once  necrosed  and  wasted 
can  never  be  restored,  this  tissue  cannot  be  made  to  re- 
new or  build  itself,  neither  can  it  be  made  to  build  around 
the  roots  of  the  teeth,  therefore,  the  cure  of  pyorrhea  is 
not  necessarily  followed  by  permanent  and  satisfactory 
tightening  of  all  the  teeth  under  all  conditions." 

Another  point  in  giving  the  patient  a  prognosis  will 
be  the  probable  condition  of  vitality  of  the  peridental 
membrane.  If  the  disease  is  in  such  an  advanced  stage 
that  this  structure  has  become  saturated  with  infection, 
or  its  nutrition  is  to  any  degree  affected,  the  chances  of 
our  being  able  to  make  a  complete  cure  are  correspond- 
ingly lessened. 

In  case  the  teeth  are  loose,  be  guarded  against  prog- 
nosis. In  other  words,  you  cannot  always  give  a  cor- 
rect prognosis  in  such  a  case.  If  the  tooth  can  be  moved 
from   side  to  side,  it  is  not  so  bad,  but  if  it  has  that 


Blood   Peessuke.  241 

".squashy"  souud  and  you  can  move  it  up  and  down  in 
its  socket,  tlie  tooth  might  as  well  be  extracted^  The  ends 
of  these  ''squashy"  teeth  often  look  as  if  a  rat  had 
gnawed  them.  This  process  is  described  by  Dr.  Hartzell 
in  the  chapter  on  ''pathology." 

When  we  find  the  tooth  which  can  be  raised  up  and 
down  in  its  socket  we  are  led  to  believe  that  there  is  little 
life  in  the  membrane  surrounding  the  tooth,  and  that  the 
terminal  end  is  covered  with  spicules  and  burr-like  pro- 
jections. When  such  teeth  are  extracted,  their  ends 
resemble  a  log  on  which  barnacles  have  collected.  Other 
conditions  might  produce  this  loosening  of  the  ligament- 
ous attachment,  as  when  the  tissues  at  the  apex  of  tlie 
socket  have  become  so  infected  that  the  ends  of  the  root 
undergo  a  process  of  absorption  similar  to  the  absorp- 
tion of  the  temporary  tooth.  If  either  one  of  these  con- 
ditions can  be  diagnosed  beforehand,  we  can  say  with 
absolute  certainty  that  the  tooth  cannot  be  saved. 

BLOOD      PEESSURE. 

Clinical  medicine  now  demands  that  the  blood  pres- 
i-ure  test  be  used  in  examinations  to  indicate  renal  or 
heart  troubles.  It  is  required  in  examinations  for  life 
insurance,  army  and  police  departments. 

Only  lately  have  dentists  begun  to  realize  the  import- 
ance in  regard  to  the  diagnosis,  prognosis  and  treat- 
ment of  pyorrhea. 

Blood  pressure  readings  are  useful  to  dentists  be- 
cause it  gives  information  about  arteriosclerosis,  chronic 
nephritis,  uremia  and  plumbism.  In  these  we  find  the 
l>ressure  high  while  in  the  following  named  diseases  we 
read  a  low  pressure:  anemia,  diabetes,  starvation  and 
exhaustion. 

The  average  pressure  of  males  should  be  1'2(),  at  the 
age  of  20.  For  each  two  years  above,  one  millimeter 
sliould  be  added.     Thus  at   the  ao-e  of  30  the  reading 


242  Pkactical  Pyoeehea  Alveolaeis. 

should  be  125.     In  women  we  find  all  readings  about  10 
millimeters  less. 

Sim])le    inexpensive   instruments    are   now    on   tlie 
market  and  have  proved  their  value  in  pyorrhea  work. 

AETIFICIAL  TEETH  IN  EEGAED  TO  PYOEEHEA. 

Every  dentist  who  treats  pyorrhea  is  frequently  met 
with  the  argument  that  "it  is  just  as  good  to  have  a  set 
of  artificial  teeth  and  much  less  trouble  than  trying  to 
save  these  I  have."  Such  a  patient  will  often  bring 
along  a  friend  who  has  a  ' '  perfect  set  of  artificial  teeth, ' ' 
and  inasmuch  as  this  friend  may  appear  quite  healthy, 
it  will  often  take  the  best  argument  at  our  command  to 
convince  our  patient  that  the  restoration  and  preserva- 
tion of  the  natural  teeth  is  superior  to  any  artificial  sub- 
stitutes. In  the  first  place  we  will  have  to  admit  that 
artificial  teeth  are  better  than  teeth  and  gums  which  are 
diseased  and  which  are  not  being  kept  clean.  But  on 
the  other  hand,  they  must  consider  the  mortification  that 
they  will  feel  when  the  teeth  are  extracted,  the  incon- 
venience of  getting  used  to  the  artificial  teeth  and  the 
danger  of  frequent  breakage,  and  of  having  to  stay 
indoors  for  days  at  a  time  while  the  teeth  are  in  a  vul- 
canizer  for  repairs.  But  greater  than  any  other  con- 
sideration is  the  fact  that  the  biting  force  of  artificial 
teeth  is  only  about  one  fourth  of  that  of  natural  teeth 
and  we  know  that  proper  mastication  of  the  food  is  of 
the  greatest  importance  in  maintaining  good  health. 


CHAPTER     XXVI. 

INSTRUMENTS  FOR  USE  IN  PROPHYLAXIS  AND 
PYORRRHEA  WORK. 

Dr.  Riggs,  of  Hartford,  is  generally  credited  with 
being  the  first  American  to  use  instruments  in  the  treat- 
ment of  pyorrhea.  The  instruments  he  used  were  very 
large  and  crude.  Some  of  his  original  shapes  are  still 
to  be  found  in  the  supply  houses. 

Considerable  evolution  has  taken  place  in  reference 
to  size  and  shape.  From  a  very  few  we  are  now  offered 
sets  of  instruments  numbering  several  hundred. 

Beginners  should  not  be  discouraged  by  the  fact  that 
pyorrhea  specialists,  though  possessing  large  sets  of 
instruments,  often  wish  they  had  a  still  greater  variety 
of  shapes  and  forms.  It  is  not  advisable  for  the  begin- 
ner to  buy  all  instruments  in  any  one  set ;  he  should  select 
a  small  number  and  add  to  them  as  needed  and  as  famil- 
iarity with  the  work  demands.  The  success  of  pyorrhea 
operations  does  not  depend  so  much  on  the  particular 
style  of  the  instruments  as  on  the  operator's  familiarity 
and  dexterity  in  their  use.  This  is  proved  by  the  fact 
that  many  of  the  contributors  to  this  book  work  with 
instruments  made  on  different  principles. 

The  dentist  in  beginning  this  work  should  select  those 
instruments  which  he  thinks  will  fit  into  the  pockets  he 
has  seen  and  should  not  attempt  to  use  the  complicated 
instruments  with  crooks  and  turns,  the  purpose  of  which 
it  takes  experience  to  appreciate. 

In  making  a  selection  of  instruments  we  should  bear 
in  mind  the  delicate  work  required.  In  addition  to  being 
sharp  and  delicate  the  blade  must  be  extra  strong.  Prob- 
ably more  is  required  from  a  pyorrhea  scaler  than  any 
other  surgical  instrument. 

Younger  says,  ''If  but  one  small  speck  is  left,  even 


24A 


Practical  Pyoeehea  Alveolaeis. 


tlioiigli  it  could  be  framed  in  the  point  of  a  pin,  the  irrita- 
tion and  bacterial  infection  maintained  by  its  presence 
wonld,  I  think,  ])revent  the  diseased  surface  frem  liealino'. 
It  is  in  the  detection  and  removal  of  these  minute  points 
that  skill  and  delicacy  of  touch  are  so  much  required." 

So  difficult  is  the  operation,  and  in  order  to  become 
efficient  and  expert  Dr.  Hartzell  said  that  on  his  infirmary 
patients'  he  frequently  scaled  a  tooth  and  pulled  it  out 
to  see  what  had  been  done.  Often  he  found  tartar  which 
had  escaped  his  instruments. 

Probably  the  best  general  class  of  instruments  for 
this  work  will  be  those  which  are  used  with  a  push  and 
those  used  with  a  pull  motion. 

The  Allport  and  Ivjirk  patterns  are  examples  of  the 
push  motion  while  those  of  Tompkins  and  Hartzell  repre- 
sent pull  motion.  The  Younger  type  has  a  point  that  can 
he  used  either  push  or  pull  motion.  The  file  type  was  popu- 
larized by  Smith.  Nearl}^  all  complete  sets  now  have 
some  instruments  with  file  points.  The  users  of  each 
variet.y  of  instruments  makes  the  claim  of  greatest  effi- 
ciency and  a  minimum  amount  of  pain  to  the  patient  in 
their  use. 


Fig.  34.     Tite  Kinic  Dental  Scalers. 

Tlie  dentate  edge  prevents  Interal   slipping.     After  their  use  smooth- 
edged  instruments  shnuld  he  used  to  make  the  surfar-e  smooth. 


Instruments. 


245 


The  Kirk  dental  scalers  are  excellent  for  re- 
moving the  large  deposits  of  salivary  tartar.  The  claims 
for  their  use  are  a  minimum  amount  of  lateral  slip- 
ping and  wounding  of  the  gums.  They  are  not  intended 
for  deep  pj'orrheal  conditions;  but  for  dense  masses  of 
deposit.  The  wedge-shaped  points  on  each  blade  cause 
the  mass  to  break  into  small  fragments  which  are  thus 
loosened  from  their  attachment.  When  used  they  must 
be  followed  by  a  smooth-edge  instrument  to  remove  the 
smaller  particles  and  to  smooth  the  surface. 

At  the  time  when  the  push  motion  instruments  were 
popular  Dr.  E.  B.  Adair  revised  the  Allport  type  of  blade 
and  added  others.  This  was  the  first  set  having 
the  end  of  the  blades  concave  on  the  cutting  side  to 
better  adapt  them  to  the  contour  of  the  root,  while  the 
back  was  rounded  to  prevent  unnecessary  irritation  or 
wounding  of  gum  tissue. 


Fig.  35.  The  R.  B. 
Adair-Alport  Pyor- 
rhea Instruments. 


246  Peactical,  Pyoerhea  Alveolaeis. 


(  1 

\ 

»                      s 

f        "^ 

(F              \ 

\ 

'        1 

Fig.    36.     The   Younger 
Pyorrhea   Instruments. 


Insteuments. 


247 


The  curved  plane  head  was  patented  by  Dr.  G-eo. 
Winkler.  Dr.  Gartrell,  of  Washington,  introduced  points 
with  blades  to  work  on  the  Japanese  plane  principal.  Dr. 
0.  W.  Jones,  of  St.  Paul,  suggested  having  the  points 
centered  with  the  long  axis  of  the  handle.  Also  a  method 
of  sharpening  the  blades  to  prevent  deep  cutting.  Dr. 
Carr  took  these  ideas  and  classified  the  instruments  into 
a  set.  Dr.  T.  B.  Hartzell  has  modified  some  points  and 
by  adding  others  has  produced  a  most  efficient  collection. 

This  set  is  probably  too  expensive  for  the  general 
practitioner  but  for  those  who  desire  to  specialize  in  this 
line  of  work  it  is  certainly  a  good  investment. 

The  W.  J.  Younger  pyorrhea  instruments  receive 
a  well  merited  large  sale.  They  have  been  con- 
densed and  modified  by  Dr.  Eobt.  Good,  of  Chicago,  into 


Fig.  3/.    The  Good  Revision  of  the  Younger  Pyorrhea 
Instrument.      Cleve-Dent. 


248 


Pkactical  Pyorrhea  Alveolaris. 


a  new  set  which  is  in  the  writer's  opinion  indispensable 
to  any  dentist  who  even  "cleans  teeth."  Dr.  Good  says: 
''These  instruments  are  made  thin,  so  they  will  pass 
under  the  gums  easily,  and  I  always  use  them  with  the 
'pull'  motion,  never  shoving,  because  the  'shove'  motion 
will  cause  pain.  The  entire  point  is  a  cutting  edge,  so 
that  it  makes  no  difference  at  what  angle  the  instrument 
is  held,  it  will  cut." 


If  18 


+    .       5  6  7  .     8  9  10  )1  la  13 

Fig.  38.     Smith's  Prophylaxis  Instruments.     Ivory. 


The  Smith  prophylaxis  instruments,  and  the  various 
modifications  l)y  other  dentists  and  manufacturers  are 
used  to  remove  deposits  from  the  roots  and  necks 
of  the  teeth.  The  smaller  oval  forms  are  for  open- 
ing into  the  diseased  pockets'.  The  large  blades  are  for 
the  interdental  spaces.  The  writer  has  the  lilade  of  No. 
13  of  this  set  made  three  times  longer  and  finds  it  most 
excellent  to  reach  deep  pockets  on  the  posterior  root 
surface  of  molars.  The  files  are  used  to  finish  with  after 
using  other  scalers. 

The  M.  H.  Fletcher  set  of  bone  curettes  and  alveolitis 
burs,  are  fully  descrilied  in  another  chapter  by  the 
inventor.  These  instruments  are  for  cutting  away 
dead  and  diseased  bone  about  and  ])eyond  the  roots  of 
the  teeth  and  are  not  styh'd  nor  intended  for  removing 
calcarious  deposits. 

The  instruments  above  described  are  the  ones  most 


Instruments. 


249 


generally  used.  Tliere  are  many  others  just  as  efficient 
for  good  work  but  nearly  all  of  tliem  are  modifications 
of  these  standard  types. 


Fig.  39.     Tompkins'  Pyorrhea  Files. 

As  many  of  the  points  are  made  in  pairs,  or  right  and 
left,  it  is  advisable,  where  possible,  to  buy  for  cone 
socket  handles. 

The  writer  prefers  a  double  end,  octogen-shaped,  hard 
rubber  handle.  These  save  handling  so  many  instru- 
ments. They  can  be  boiled.  The  shape  and  size  is  just 
right  to  prevent  cramping.  Younger  and  Good  use  the 
various  colored  sealing  wax  knobs  on  their  handles  for 
this  purpose,  while  Sarrazin  has  aluminum  knobs  with 
set  screws,  to  use  on  small  handles  for  the  purpose  of 
preventing  slipping  and  cramping  of  the  hand  from 
long  use. 


CHAPTER     XXVII. 
TREATMENT  AND  INSTRUMENTATION 

THE    YOUNGER    METHOD.- — STRONG    DRUGS    USED    AND    OBJEC- 
TIONS   TO    THEIR   USE. THE    JOSEPH    HEAD    METHOD 

If  there  is  one  general  criticism  that  can  be  made 
against  the  dental  profession  it  is  in  regard  to  the  gen- 
eral method  of  dealing  with  patients  presenting  them- 
selves with  cases  of  pyorrhea.  It  has  been  the  experience 
of  all  of  ns  who  have  treated  a  considerable  nnmber  of 
such  cases  to  see  patients  with  merely  a  condition  of 
slight  irritation  of  the  gnm  margins  who  had  been  in- 
formed by  some  dentists  that  their  case  was  incurable. 
We  find  that  dentists,  as  a  general  rule,  do  not  like  to 
treat  these  cases,  preferring  to  throw  them  off  with  the 
simple  statement  that  the  case  is  incurable.  This'  cer- 
tainly lessens  the  respect  of  the  patients  for  the  dental 
profession,  but  of  much  greater  importance  is  the  fact 
that  it  means  the  loss  of  many  teeth  which  should  have 
been  saved;  the  patient,  believing  absolutely  in  the 
integrity  of  the  dentist,  has'  gone  on  and  on  without  seek- 
ing other  aid. 

If  a  splinter  should  stick  in  the  finger  the  tissue 
soon  turns  red  and  suppuration  takes  place.  Now,  exactly 
the  same  thing  takes  place  in  the  mouth.  If  a  dentist 
should  stick  a  splinter  in  his  hand,  he  probably  would 
not  inject  any  of  the  strong  pyorrhea  remedies.  Rather 
he  would  remove  the  cause.  The  same  thing  is  true  in 
pyorrhea.  The  pathology  of  the  tissue  surrounding  the 
splinter  is  the  same  as  that  which  makes  the  red  tinge 
on  the  gums  and  the  final  suppuration.  The  pathological 
picture  is  simple  and  plain;  Dr.  Tolbot  goes  so  far  as  to 
say  that  the  dentist,  allowing  a  patient  affected  with 
disease  to  go  out  of  his  office  without  telling  him  of  his 


Teeatment  of  Pyokrhea  Alveolaeis.  251 

condition,  is  guilty  of  mal-practice.  Incipient  pyorrhea 
is  easily  cured.  Just  as  removing  the  splinter  cures  the 
finger,  so  incipient  pyorrhea  will  get  well  in  a  few  days 
if  the  teeth  are  cleansed  and  the  tartar  removed  from 
under  the  gum  margin. 

Every  dentist  should  know  the  facts,  now  so  well 
established  regarding  the  beginning  of  this  disease;  no 
matter  what  the  condition,  a  great  deal  can  be  accomp- 
lished b}^  treatment  that  is  simple  and  easy,  giving  the 
patient  great  relief  and  saving  teeth  for  future  service. 

Of  course,  it  must  be  realized  that  hard  work  will 
often  not  be  paid  for  at  the  fees  we  are  accustomed  to 
receive  for  other  work;  but  if  we  do  our  duty  towards 
this  end,  we  will  soon  become  more  expert  and  in  time 
our  success'  will  enable  us  to  receive  reasonable  compen- 
sation. 

Dr.  D.  D.  Smith  says:  ''Pyorrhea  alveolaris  is  by  no 
means  a  subject  to  be  treated  in  a  hit  or  miss  haphazard 
manner ;  it  is  a  foe  worth}^  of  the  steel  of  a  valiant  aggres- 
sor and  consequently  requires  careful  consideration, 
a  steady  hand,  a  keen  sense  of  touch,  and  sound  judg- 
ment. ' ' 

Dr.  M.  M.  Bettman,  of  Portland,  Oregon,  says:  ''The 
main  point  in  the  treatment  of  pyorrhea  is  the  thorough 
scaling  and  polishing  of  the  roots  and  the  correction  of 
any  malocclusion  which  mav  exist,  no  matter  how 
slight." 

Dr.  E.  G.  Hutchinson,  Jr.,  says : 

"The  time  will  never  come  when  every  dentist  can 
successfully  treat  pyorrhea.  It  is  unreasonable  to  expect 
that  what  requires  special  training  can  be  accomplished 
by  one  who  only  occasionally  engages  in  such  practice. 
It  is  also  unreasonable  to  believe  that  because  the  opera- 
tion cannot  be  accom])lished  by  the  majorit\^  it  is 
impossible." 

The  Younger  method,  as  carried  out  ])y  Good  and 
others'  of  this  school,  consists  of  first  thoroughlv  remov- 


252  Practical  Pyorehea  Alveolaeis. 

ing  all  concretions  and  carious  bone,  tlien  injecting  pure 
warm  lactic  acid  into  these  cleansed  pockets,  with  care 
that  it  does  not  run  over  the  external  gum  margin.  This 
is  effected  by  the  use  of  a  small  caliber,  round  pointed 
steel  needle  on  a  hypodermic  syringe.  The  particular  one 
as  used  by  Grood,  can  be  procured  from  Sharp  &  Smith, 
of  Chicago. 

This  treatment  is  repeated  three  or  four  times  at 
intervals  of  several  days'  and  only  a  few  teeth  are  treated 
at  a  sitting.  The  object  of  this  treatment,  as  claimed  by 
these  operators,  is,  that  the  acid  produces  somewhat  of  a 
solvent  effect  upon  whatever  concretions  have  remained 
and  also  upon  the  carious  bone.  In  addition  to  this,  it 
has  a  somewhat  stimulating  effect  on  the  granulation 
tissue  which  surrounds  the  tooth  roots  and  a  new  attach- 
ment is  formed. 

"Wliile  it  is  undoubtedly  true  that  this  treatment  has 
produced  good  results  it  is  just  as  true  that  their  method 
cannot  be  said  to  be  without  objection.  I  believe  the 
success  that  they  obtain  can  be  attributed  more  to  the 
thorough  cleansing  of  the  pocket  than  to  the  injection 
of  this  acid. 

I  am  led  to  believe  that  the  same  result  could  be  ob- 
tained by  the  injection  of  almost  any  other  strong  drug 
such,  for  instance,  as  Tartar  Solvent  which,  it  is  said, 
does  not  have  the  disadvantage  of  dissolving  the  tooth 
root.  If  you  will  place  a  tooth  root  in  pure  lactic  acid 
and  allow  it  to  remain  for  twenty-four  hours,  it  becomes 
changed  into  a  jelly-like  mass.  This  is  prevented  in  the 
mouth  by  the  fact  that  the  injection  remains  only  a 
minute  before  it  is  washed  out  by  the  surrounding 
liquids,  but  there  is  the  possibility  that  some  of  it  may 
be  retained  in  a  remote  cavity. 

One  of  the  most  perplexing  cases  that  I  have  had  to 
diagnose  was  that  of  an  army  officer  who  had  been 
treated  by  the  lactic  acid  method.  He  had  received  great 
benefit  from  the  treatment,  but  from  time  to  time  he 


Treatment  of  Pyorrhea  Alveolaris.  253 

suffered  excruciating  pain  on  the  side  which  had  been 
treated.  Several  examinations,  at  intervals,  were  made 
in  an  endeavor  to  diagnose  the  cause  of  this  trouble,  but 
without  success  until  an  X-Eay  was  made  that  showed 
a  cavity  in  the  upper  cuspid  root  about  the  middle  third. 
The  instrument  was  inserted  through  the  old  pocket 
opening  and,  when  high  enough,  fell  into  this  cavity. 
The  patient  almost  leaped  out  of  the  chair  with  pain. 
There  was  nothing  that  could  be  done  except  to  extract 
the  tooth.  It  was  found  that  the  constant  application  of 
this  acid  had  dissolved  the  tooth  with  the  final  result  of 
exposure  of  the  pulp.  There  was  no  sign  of  decay  ex- 
cept such  as  acid  produces  on  tooth  substance.  While 
this  is  probably  a  rare  termination  of  the  treatment,  at 
the  same  time,  it  is  well  to  call  attention  to  the  possibility 
of  this  complication  occurring  in  deep  pockets.  Another 
objection  to  the  filling  of  these  pockets  with  this  or  any 
other  strong  drug,  is  the  great  amount  of  pain  which 
sometimes  accompanies  such  treatment.  It  is  well,  if 
possible,  to  secure  some  degree  of  anesthesia  of  these 
sensitive  teeth  before  subjecting  them  to  the  pain  of  this 
treatment. 

Another  drug  used  by  many  is  trichloracetic  acid. 
After  thorough  instrumentation,  sections  of  the  gnim 
are  dried  with  cotton  rolls  or  napkins  and  the  pockets  are 
saturated  with  a  ten  per  cent,  solution  of  trichloracetic 
acid,  using  small  ropes  of  cotton,  or  wood  tooth  picks. 
This  treatment  is  repeated  in  three  or  four  days  but 
should  not  be  used  more  than  three  applications. 

After  the  operation  of  curetting  out  these  pockets, 
if  suppuration  continues.  Dr.  Kelsey  recommends  the  use 
of  phenol-sulphonic  acid  to  be  applied  with  a  small 
pointed  wood  applicator. 

Deliquesced  chloride  of  zinc,  very  slightly  diluted,  ap- 
plied on  small  wood  applicators  into  pockets,  has  some 
advocates. 

Fieler,  of  the  Eoyal  University  of  Breslau,  modifies 


254  Practical  Pyoeehea  Alveolaris. 

the  Younger  treatment  as  follows :  "After  scraping  away 
deposits,  the  teeth,  including  their  necks,  are  polished  and 
when  they  have  been  dried  we  introduce  iodine  or  lactic 
acid  and  iodine  tincture  because  the  former  is  borne 
badly  on  account  of  its  nasty  taste,  and  also  because  in 
some  cases  it  produces  severe  pain.  I  introduce  both 
medicants  into  the  pockets  on  Ja])anese  bibulous  ]^aper 
wound  around  nerve  needle.  Often  from  two  to  four 
medical  after-treatments  suffice,  carried  out  once  or 
twice  a  week." 

The  result  obtained  by  the  use  of  these  drugs  is  the 
cicatrization  of  the  tissue. 

Several  years  ago,  Dr.  Joseph  Head,  of  Philadelphia, 
gave  a  most  sensational  report  claiming  that  bifluoride 
of  ammonia  has  a  'most  peculiar  action  of  dissolving 
tartar  from  the  teeth  without  harming  the  tooth  struc- 
ture. As  teeth  and  tartar  are  the  same  chemically,  this 
seemed  most  remarkable.  This  preparation  has  a  place 
in  the  treatment  of  pyorrhea  and  we  quote  at  length  from 
his  own  description  of  this  method.  One  precaution  that 
must  be  observed  is  to  secure  a  suitable  syringe,  prefer- 
ably the  celluloid  syringe.  This  holds  a  small  quantity 
and  will  deliver  drop  by  drop.  Dr.  Head  tlius  describes 
his  method: 


Fig.   40.     Cklluloid    Syringe   with    Plattnum    IVjint. 
No  flooding  of  the  nioiilli.  Oiu;  or  two  dro|).s  at  tlic  IjoIIomi  oI'  llic 

|)ocket. 

''Through  an  extensive  series  of  experiments  it  was 
proven  that  a  twenty  to  twenty-three  per  cent,  solution 


Treatment  of  Pyorrhea  Alveolaris.  255 

of  bifluoricle  of  aniiiionia  (aii  acid  salt  of  liydrofluoric 
acid)  will  disintegrate  the  tartar  on  a  tooth  as  readily  as 
hydrofluoric  acid  itself  and  also  leave  the  tooth  apparent- 
ly unsoftened.  Later  experiments  have  shown  that  this 
solution  can  also  be  applied  to  the  gums  with  the  most 
beneficial  effects,  as  it  seemingly  stimulates  the  tissues 
and  diseased  bone  to  such  healthy  action  that  deep 
pockets  around  loose  teeth  speedily  fill  up  with  healthy 
firm  tissue  and  the  sensitive  teeth  are  reunited  to  the 
gums,  becoming  secure  and  useful  agents  in  the  process 
of  mastication.  After  one  or  two  injections,  the  soreness 
will  largely  disappear  and  all  the  tartar  scale  that  could 
not  be  so  easily  and  painlessly  removed  at  the  first  two 
sittings  tends  to  be  so  loosened  that  its  thorough  j^emoval 
by  the  scalers  is  easy  for  both  patient  and  dentist.  After 
four  or  five  applications,  one  week  apart,  black  scales 
that  have  escajDed  the  scaler  will  sometimes  be  found 
floating  loose  in  the  pocket  so  that  they  can  be  readily 
picked  out  and  the  root  will  be  as  smooth  as  velvet  to 
the  touch  of  the  instrument. 

"In  closing,  perhaps,  it  would  be  well  to  tersely  run 
over  the  steps  of  my  treatment  of  pyorrhea.  Take  off  all 
tartar  tliat  can  easily  be  removed  and  cleanse  the  mouth 
as  thoroughly  as  can  be  painlessly  accomplished,  at  the 
same  time  instructing  the  patient  in  the  use  of  brush, 
floss  silk  and  mouth  wash,  pointing  out  particularly 
where  he  fails  to  reach  the  bacterial  plaques,  and 
demonstrating  what  motions  of  the  brush  are  neces- 
sary to  remove  the  plaques.  The  syringe  should  then 
be  filled  with  bifluoride  of  ammonia  and  the  platinum 
point  inserted  near  to  the  bottom  of  the  pocket  or 
pockets,  which  should  be  filled  full  from  the  bottom  to 
the  top.  During  the  operation  of  injecting  the  pockets, 
the  cheek  and  tongue  may  be  guarded  with  napkins  with 
which  all  excess  or  overflow  should  be  wiped  away.  Then 
the  patient  should  be  allowed  to  spit  for  a  minute  or  two 
when  the  mouth  may  be  slightly  rinsed  with  water  to 


256  Peacticax,  Pyoeehea  Alveolaeis. 

remove  any  excess  of  acid.  Less  irritation  to  the  mucous 
membrane  occurs  from  this  method  than  that  formerly 
advocated,  which  consisted  in  allowing  the  solution  to 
rest  in  the  pocket  for  a  minute  or  two  minutes.  The 
patient  is  then  dismissed  with  the  instruction  to  return 
in  a  week.  He  is  also  cautioned  to  carefully  observe  all 
directions  on  home  prophylaxis.  When  he  returns  next 
week  the  teeth  are  again  scaled  as  far  as  feasible,  clean- 
ing them  thoroughly  with  brush  and  pumice  and  a  coat- 
ing of  tincture  of  iodine.  When  this  is  finished  another 
application  of  the  bifluoride  is'  made  as  before.  The 
procedure  for  the  third  sitting  is  as  for  the  second,  but 
usually  after  that  the  teeth  are  free  from  tartar,  the 
pockets  have  started  to  heal  and  the  treatments  need  be 
for  a  period  of  only  about  fifteen  minutes,  just  long 
enough  for  the  application  of  the  bifluoride  and  the  little 
cleaning  and  scaling  required.  The  bifluoride  should  not 
be  applied  oftener  than  twice  a  week  and  usually  once  a 
week  is  more  desirable.  Of  course  loose  teeth  should  be 
tied  to  their  secure  neighbors  whenever  feasible." 


CHAPTER     XXYIII. 

THE  AUTHOR'S  METHOD  AND  SYSTEM  OF 
TREATING  PYORRHEA. 

For  the  first  time  the  author  is  afforded  the  proper 
opportunity  of  giving  in  full  detail  each  step  in  a  sys- 
tematized method  of  treatment  which  has  for  many 
years  proved  highly  efficient  in  his  practice. 

"While  many  papers  have  been  read  and  published 
and  clinics  given,  only  parts  of  his  work  could  be  presen- 
ted. For  this  reason  many  of  these  contributions'  were 
not  thoroughly  understood  nor  were  the  methods  gener- 
ally adopted;  but  the  author  has  the  satisfaction  of 
knowing  that  some  dentists  who  have  visited  his  office 
and  seen  his  methods  in  practice  have  adopted  them  suc- 
cessfully. 

The  author's  treatment  having  proved  so  successful 
in  his  own  hands,  it  is  herewith  given  in  full  detail  with 
the  hope  that  it  may  prove  equally  useful  to  others. 

The  instruments  which  the  author  uses  consist  of  the 
following :  R.  B.  Adair  revision  of  the  Alport ;  the  Smith 
set  of  files  with  the  author's  modification;  Good's  revis- 
ion of  the  Younger;  the  Fletcher,  and  the  Hartzell  sets. 
As  the  manner  of  using  the  above  sets  are  fully  described 
elsewhere,  this  part  of  the  work  is  omitted  from  this 
chapter.  The  author  believes  that  proper  instrumenta- 
tion is  the  only  solution  for  the  cure  of  pyorrhea.  He 
does  not  claim  that  the  above  mentioned  instruments  are 
superior  to  all  others,  or  that  they  are  entirely  adequate 
for  every  requirement. 

In  the  description  of  this  treatment  we  will  consider 
that  we  have  a  case  of  pyorrhea  where  the  teeth  are 
loose,  the  gums  swollen,  and  the  pockets  are  of  medium 
depth  containing  some  cheesy  disintegrated  lalveolus, 
in  other  words,  a  typical  case  of  pyorrhea. 


258  Peactical  Pyorrhea  Alveolaris. 

Several  days  before  the  surgical  work  the  patient  is 
given  several  sittings,  at  which  time  the  month  is  spray- 
ed ont  with  some  antiseptic  solution  or  AA  Dental  Mouth 
Wash.  Each  time  the  mouth  is  mopped  ont  with  a 
"Knoris,"  the  cotton  having  been  dipped  in  a  weak  solu- 
tion of  hydrogen  peroxide  and  then  applied  to  the  gum 
surfaces.  A  coating  of  Skinner's  Disclosing  Solution 
(formula  given  elsewhere)  is  next  applied;  other  good 
antiseptic  solutions  for  this  preliminary  treatment  are: 

DR.     MEDALIA's     mild     ANTISEPTIC  DR.     BUCKLEy'S     PYORRHEA 

SOLUTION  ASTRINGENT 

Compound    solution    of    iodine         Potassium  iodide 

(U.    S.   P.)                                    Zinc  phenol  sulpbonate  aa  grs.  60 

Glycerine                      aa  gTS.  s  s         Iodine  grs.  80 

Distilled  Avater                   grs  II         Water  m       192 

Glycerine  grs.  100 

Any  one  of  these  three  preparations  is  good.  They 
are  applied  on  gums  with  a  cotton  pledget  wound  round 
a  toothpick  or  with  a  camel  hair  brush. 

This  preliminary  treatment  has  the  advantage  of 
getting  acquainted  with  the  patients,  gaining  their  con- 
fidence, and  getting  rid  of  any  bad  odor.  By  staining  the 
debris  around  the  tooth  it  is  more  easily  removed. 

On  the  hour  of  appointment  for  the  operation  the 
room  and  instruments  are  prepared  just  as  for  any  other 
surgical  operation.  All  the  instruments  needed  for  the 
operation  are  thoroughly  cleaned  and  sterilized,  the  in- 
strument table  is  wiped  off  with  alcohol  and  a  sterile 
napkin  is  placed  on  the  table,  upon  which  are  laid  all  of 
the  instruments. 

Tlie  7)oint  of  l)eginning  tlie  operation  having  been 
sel('ct(;d — generally  tlie  right  side  of  the  upper  teeth — this 
section  of  tlie  gums  is  dried  oif  with  cotton  or  bibulous 
paper  and  either  a  solution  of  5  per  cent  cocain  is  applied 
or,  better  still,  a  fresh  solution  of  cocain  and  adrenalin 
as  prepared  by  the  Park-Davis'  Company.    Also,  of  late, 


Treatment  of  Pyoerhea  Alveolaeis.  259 

a  preparation  called  ^  ^  Peritimdo, "  put  up  by  the  J.  W. 
Edwards  Co.,  of  San  Francisco,  lias  been  used  with  ex- 
cellent results.  This  preparation  contains  eucain  and 
adrenalin.  You  make  your  solution  fresh  for  each  case. 
The  anesthesia  obtained  from  this  preparation  is  fine 
and  it  gives  the  minimum  amount  of  hemorrhage.  The 
anesthetic  is  inserted  into  the  pocket  with  a  clean  hypo- 
dermic syringe,  using  for  the  purpose  a  long  steel  point. 
Do  not  use  a  sharp  needle. 

The  Sharp  and  Smith  needle  is  most  useful,  the  point 
is  small  and  not  expensive  and  better  than  anything  I 
have  found  or  had  suggested  to  me  for  general  use. 

Five  or  six  teeth  having  been  anesthetized,  we  are 
now  ready  for  the  surgical  work.  Great  care  must  be 
exercised  that  the  gingival  margin  be  not  injured  for  at 
this  border  there  seems  to  be  a  fibre  which  acts  like  the 
draw  strings  on  a  tobacco  sack  and  when  once  severed, 
it  is  never  reunited.  It  is  a  good  plan  to  pack  small 
shreds  of  cotton  saturated  with  the  anesthetic  into  the 
spaces  between  the  teeth,  keeping  the  portion  free  from 
saliva  for  a  few  moments  until  complete  anesthesia  is 
obtained.  Generally  the  beginning  of  pyorrhea  at  the 
gingival  border  is  more  painful  than  the  deep  pockets  so 
this  method  is  most  important  to  use. 


Fig.  41.    A  Small,  Inexpensive  Steel  Point  Essential  in  Pyoerhea 

Work. 

We  endeavor  to  use  the  instruments  so  as  to  give  the 
minimum  amount  of  pain.  However,  it  sometimes  hap- 
pens that  the  very  case  in  which  we  expect  the  least  pain, 
is  the  most  sensitive.  The  patient's  fears  are  allayed 
when  they  see  the  operator  is  taking  steps  to  prevent 
pain. 


260  Peactical.  Pyoeehea  Alveolaris. 

In  a  systematic  way  begin  at  tlie  gingival  opening  of 
pocket  and  gradually  proceed  towards  the  apex  of  the 
tooth  nntil  the  sense  of  touch  tells  us  that  the  instrument 
has  removed  all  deposit  and  dead  membrane  and  reached 
the  extreme  de^Dth  of  the  pocket. 

While  each  instrument  is  in  the  hands  of  the  opera- 
tor, he  should  operate  on  just  as  much  surface  of  the 
tooth  or  teeth  as  possible,  that  is,  he  should  go  as  far  as 
he  can  before  another  instrument  is  taken  up. 

Wlien  through  with  an  instrument  or  before  placing 
it  in  a  new  location  or  pocket  it  is  dipped  in  a  glass 
having  an  inch  of  its  depth  filled  with  smallest  size  shot 
covered  with  antiseptic  solution.  By  dipping  instru- 
ments into  this  glass  we  not  only  disinfect  the  point  but 
the  shot  effectually  cleans  the  edge  from  any  adhering 
matter  or  blood  clot. 

Each  selected  section  is  taken  up  and  finished  before 
scaling  other  teeth.  A  section  as  spoken  of  means  from 
three  to  four  teeth. 

The  ^'root  planing"  having  been  completed,  I  take 
the  proper  Smith's  files  and  smooth  otf  all  roughness 
which  may  remain  or  possible  grooves  cut  in  the  teeth. 
With  Adair's  small  bone  curette  the  disintegrated  bone 
and  sharp  edges  of  the  alveolus  are  most  carefully  re- 
moved, its  point,  having  a  rounded  end,  will  not  remove 
sound  tissue.  Any  carious  bone  or  sharp  corners  of 
alveolus  would  retard  the  healing  of  tissue  over  it.  A 
delicate  sense  of  touch  and  experience  is  imperative  in 
using  a  curette  in  pyorrhea  work. 

One  of  the  greatest  aids  for  thorough  work  is  the  use 
of  a  good  compressed  air  syringe,  such  as  that  made  by 
the  A.  C.  Clark  Co.  However  any  of  the  syringes  applied 
with  switch-boards  would  answer.  This  one  is  the  least 
in  the  way. 

A  stream  of  warm  compressed  air  at  from  twenty-five 
to  forty  pounds  is  directed  into  the  pocket  and  if  the 
latter  contains  any  foreign  material,  calculus  or  serumal 


Treatment  of  Pyorrhea  Alveolaris.  261 

tartar,  it  can  generally  be  seen.  This  syringe  can  be 
handled  by  the  operator  but  it  saves  time  to  have  the 
assistant  trained  to  do  it. 


^ 


Fig.  42.     The  Clark  Air  Syringe,  Which  the  Author  Finds  the 
Best  for  His  Work. 

In  working  on  the  lower  jaw,  it  is  advisable  to  have 
the  saliva  ejector  in  place,  nsing  the  compressed  air 
syringe  in  the  manner  above  described.  The  air  distends 
the  gum  from  the  tooth  so  that  with  the  mirror,  the 
operator  can  see  and  remove  the  smaller  deposits  which, 
when  dry,  show  up  so  much  better  than  when  in  a  moist 
condition. 

When  cleaning  teeth  or  removing  tartar,  place  the 
electric  mouth  light  on  one  side  of  the  alveolus  opposite 
the  root  of  tooth  to  be  cleaned ;  you  will  be  able  to  locate 
the  tartar  on  the  opposite  side  and  by  reversing  the 
light  from  side  to  side,  enables  the  operator  to  find  tartar 
deposits  even  if  they  extend  almost  to  the  apex  of  the 
roots. 

Having  satisfied  myself  that  the  teeth  are  surgically 
clean  and  that  the  disintegrated  bone  and  sharp  edges 
of  the  alveolus  are  rounded  off  so  that  the  soft  tissue  or 
gum  can  festoon  itself  over  the  surface  without  any 
irritation  from  projecting  bone,  the  entire  surface 
operated  upon  is  then  washed  out  with  a  liberal  supply 
of  warm  water,  normal  salt  solution,  or,  better  still,  an 
antiseptic  solution  such  as  AA  Dental  Mouth  Wash. 
This  solution  is  placed  in  a  spray  bottle,  having  for  a 
point  the  Good  needle  which  we  advised  for  use  in  the 
hypodermic  syringe.  Plenty  of  solution  should  be  used; 
a  full  spray  bottle  is  not  too  much  for  each  tooth. 

Another  apparatus  which  I  use  with  good  results  is 


262  Practical,  Pyoeehea  Alyeolaeis. 

that  used  by  Dr.  Conrad  Deichmiller,  of  Los  Angeles, 
consisting  of  a  Valentine  irrigator  placed  near  the  ceiling 
and  a  common  bulb  s^^ringe  inserted  at  the  end  of  tube 
to  get  a  greater  pressure.  This  is  not  only  a  useful 
apparatus  for  the  treatment  of  pyorrhea,  but  in  other 
dental  surgery  as  well,  such  as  washing  out  the  antrum, 
abscesses,  etc.  A  quart  of  hot  normal  salt  solution 
should  be  used  in  this  apparatus.  (Normal  salt  solution 
is  made  by  adding  one  dram  of  salt  to  a  pint  of  sterile 
water.) 

Tlie  entire  area  of  the  diseased  gums  is  thus  syste- 
matically gone  over  in  turn.  AVhatever  success  the 
author  has  had  in  the  work,  he  believes  it  is  due  to  the 
thoroughness  with  which  the  surgical  technique  is  car- 
ried out.  If  any  scale  of  deposit,  any  carious  bone,  or  a 
sharp  edge  is  left,  that  particular  place  will  not  heal, 
and  if  it  shows  up  before  the  patient  is  dismissed  the 
pocket  is  again  opened  up  and  this  irritant  removed. 

Thorough  irrigation  with  plain  warm  water  or  nor- 
mal salt  solution  is  used  for  no  other  purpose  than  that 
it  will  wash  out  the  debris.  AVe  do  not  use  any  solution 
which  would  tend  to  destroy  or  prevent  organization  of 
the  clot.  It  would  be  preferable  not  to  wash  out  the 
pockets  after  instrumentation  were  it  not  for  the  fact 
that  loosened  scales  of  deposit  might  remain  to  become 
reattached  and  give  future  trouble.  If  nothing  stronger 
than  the  solution  named  be  used  for  irrigation,  we  find 
that  we  have  as  good  blood  clot  as  though  the  thorough 
washing  had  not  been  done. 

It  matters  little  whether  all  the  teeth  are  completed 
at  one  sitting  or  not,  as  the  field  operated  upon  is  sealed 
from  infection  from  the  other  parts  of  the  imouth.  Wliat- 
ever  section  is  oijerated  upon,  must  be  finished  at  this 
time;  if  this  is  not  done,  when  the  patient  returns  in  a 
day  of  two  for  another  hour  of  surgical  work,  we  will 
probably  liave  forgotten  just  where  we  left  off  or 
whether  or  not  we  have  finished  certain  teeth. 


Treatment  op  Pyoerhea  Alveolaris.  263 

In  our  operative  procedure,  we  will  find  fillings 
which  have  a  shelf  overhanging  the  entrance  to  a 
pyorrhea  pocket  and  the  operator  is  prone  to  leave  this 
for  future  consideration.  However,  as  we  have  given 
this  as  a  causative  factor,  it  should  be  eliminated  almost 
as  soon  as  found.  Sometimes  the  quicker  way  to  do  this 
is  to  remove  the  filling  and  put  in  some  temporary  stop- 
ping, waiting  until  we  have  finished  the  operation  and 
can  knuckle  the  filling  up  in  the  proper  manner  without 
any  overhanging  edges ;  ill  fitting  crowns  and  bridges 
should  also  be  promptly  removed. 

Sometimes  the  deposit  of  tartar  is  so  hard  that  it  is 
good  practice  to  remove  it  with  a  burr,  placed  in  the 
dental  engine.  It  is  well  to  first  allow  the  burr  to  revolve 
against  a  stone  so  as  to  modify  its  cutting  qualities  in 
order  that  it  will  not  gash  into  the  tooth  root  itself.  The 
burs  with  long  shanks  and  small  heads,  as  described  by 
Dr.  Fletcher,  can  be  used  to  advantage  in  removing 
carious  bone  or  cleaning  out  between  the  roots  of  the 
teeth  when  it  is  not  practicable  to  obtain  sufficient  force 
or  effectiveness  with  a  hand  instrument. 

I  expect  the  same  healing  that  I  would  from  any 
fresh  wound  which  is  filled  with  a  blood  clot.  I  do  not 
mutilate  the  gum  at  the  cervical  border.  T  endeavor  to 
have  the  operation  joractically  painless  and  without  any 
great  strain  on  the  patient.  While  our  object  has  been 
to  produce  a  clean  wound  sometimes  after  treating  for 
a  few  da3"s,  we  will  find  a  trace  of  pus  which  shows  that 
something  has  been  left  in  the  pocket  which  must  be 
removed.  In  such  an  instance  it  will  be  necessary  to 
again  open  up  the  pocket  or  to  inject  some  medicant  to 
overcome  the  infection  which  has  spread  into  the  body 
of  the  alveolus. 


CHAPTER     XXIX. 

THE  AUTHOE'S  METHOD  AND  SYSTEM  OF 
TREATING  PYORRHEA- CONTINUED. 

THE    MEDICAL,    TEEATMENT. PEACTICAL    HINTS    FOR    APPLICA- 

TION. AN"  UNEXPLAINED  CHEMICAL  FORMATION 

USEFUL   IN    TREATMENT 

Many  cases  would  undoubtedly  get  well  with  the  sur- 
gical procedure  alone,  but  no  medical  treatment  known 
will  aid  these  cases  unless  this  surgical  procedure  has 
been  well  done.  However,  in  the  same  patient,  with  the 
same  degree  of  operation  on  both  sides  of  the  jaw,  I 
have  tried  the  experiment  of  using  my  medical  dressing 
preparation  on  one  side  only.  For  the  first  few  days  the 
side  not  dressed  showed  inflammation,  the  teeth  were 
elongated  ,and  it  was  very  sore  to  touch,  while  the  op- 
posite side  where  the  preparation  was  used  showed  no 
such  symptoms.  The  reason  for  this  is  logical.  A  sur- 
geon who  had  performed  an  operation,  follows  it  by  ap- 
plying a  dressing  which  has  a  great  deal  to  do  with  the 
proper  healing  of  the  wound.  For  years  the  dental  pro- 
fession tried  and  experimented  in  an  effort  to  get  some 
method  of  covering  the  operated  surface  in  pyorrhea 
work.  Some  have  tried  sponge  grafting;  some,  tying 
strijos  of  rubber  dam  about  the  teeth;  still  others,  pack- 
ing the  pocket  with  strong  irritating  drugs.  The  diffi- 
culty that  we  have  hitherto  had  was  that  the  treatment 
or  medicament  could  not  be  kept  in  place.  It  was  im- 
mediately washed  off  by  the  constantly  flowing  saliva. 
The  failure  to  use  a  suitable  protection  left  the  field  of 
operation  a  veritable  culture  tube — the  mouth  contain- 
ing stagnant  saliva,  decayed  teeth,  and  many  different 
kinds  of  bacteria.  Hitherto,  the  antiseptics  we  have  used 
have  proved  failures,  for,  if  strong  enough  to  destroy  the 


Treatment  op  Pyorrhea  Alveolaris.  265 

bacteria,  tliey  destroyed  the  membrane  of  the  mouth  or 
kept  it  in  a  raw  state. 

Some  years  ago,  Dr.  R.  B.  Adair,  made  a  solution  of 
iodine,  creosote,  tannin,  chlorate  of  potash  and  glycerine. 
He  was  most  successful  with  this  treatment,  but  the  com- 
bination was  difficult  to  make  and  it  was  not  stable.  He 
gave  the  formula  to  the  profession  but  few  men  had  done 
anything  with  it.  It  was  hardly  possible  to  get  a  pre- 
scription for  this  preparation  filled  jDroperly  as  the  con- 
sistency more  than  the  quantity  was  the  requisite.  In 
attempting  to  get  it  filled  at  drug  stores,  I  found  diffi- 
culty in  getting  it  just  right.  I  improved  this  formula 
and  in  order  to  supply  the  prescription  to  those  dentists 
who  had  shown  an  interest  in  it  and  wished  to  give  it 
a  trial  I  had  the  preparation  placed  upon  the  market 
under  the  trade  name  of  "AA  Pvorrhea  Treatment  Nos. 
land  2." 

Tfhis  preparation  was  shown  for  the  first  time  last 
year  (1913)  at  the  National  Dental  Association  at  Wash- 
ington. I  not  only  wished  to  give  the  profession  the  op- 
portunity of  using  this  '^ dressing"  that  had  filled  a  long 
felt  want  in  my  practice,  but  also  to  stimulate  others  to 
investigate  the  nature  of  this  preparation.  I  certainly 
do  not  know  and  no  one  has  been  able  to  find  out,  al- 
though some  of  the  most  prominent  men  in  the  profes- 
sion have  successfully  used  it  for  sometime.  The  name 
treatment  is  a  misnomer ;  it  should  be  dressing,  as  it  can 
be  used  in  combination  with  any  treatment. 

METHOD   OF   MAKING   NOS.    1   AND   2    PYORRHEA   DRESSING. 

ORIGINAL    PORMULAE    BY    DR.    R.    B.    ADAIR. 

Take  one  oz.  chemically  pure  iodine  crystals.  Pour 
over  this  just  enough  chemically  pure  beachwood  creo- 
sote to  cover  crystals  of  iodine.  Let  stand  for  48  hours, 
then  stir  thoroughly  with  a  glass  or  wood  rod,  making 
a  thick  mixture.  When  this  is  settled,  pour  off  from 
sediment  at  bottom.    This  liquid  is  the  No.  1  preparation. 


266  Practical  Pyorrhea  Alveolaris. 

Procure  large  moiith  bottle  of  about  3  oz.  capacity 
STicli  as  vaseline  comes  in.  Pack  into  such  a  bottle  tannic 
acid  crystals.  Use  a  wood  rod  and  pack  tight,  having  one- 
half  inch  space  at  the  top  of  bottle.  Into  this  space  pour 
Glycerine  C.  P. — about  one-half  oz.  Let  stand  for 
several  days.  If  on  examination  the  glycerine  seems  to 
have  reached  the  bottom,  place  it  on  a  water  bath  and 
leave  until  the  whole  has  become  a  thick  syrup.  If 
glycerine  has  not  reached  the  bottom,  add  a  small  quan- 
tity of  glycerine.  After  heating  on  water  bath,  mixture 
should  stand  and  age  for  about  a  week.  The  mixture 
will  become  clear  and  will  have  the  consistency  of  thick 
molasses.    This  is  the  No.  2  preparation. 

These  preparations  are  rather  hard  to  make  in  small 
quantities.  They  must  be  just  the  proper  consistency 
which  is  best  obtained  by  aging.  The  preparation  as 
manufactured  stands  several  months  before  bottling. 

'Simple  cases  will  need  only  three  or  four  applica- 
tions ;  the  severity  of  the  condition  and  the  extent  of  the 
operation  determine  the  number  of  applications  neces- 
sary. This  ''dressing"  does  not  stain  a  clean  tooth — 
really  bleaches  it — but  it  does  stain  every  bit  of  foreign 
matter  on  the  tooth  root.  I  have  found  it  a  good  idea 
to  use  a  few  applications  before  the  operation  as  a  sub- 
stitute for  a  disclosing  solution,  as  this  staining  will  show 
up  the  tartar  and  other  accumulations'.  It  softens  and 
loosens  the  attachment  of  accumulations.  This  "dress- 
ing" which  we  use  comes  nearer  filling  all  requirements 
than  anything  yet  found.  It  furnishes  the  strongest  anti- 
septic known  and,  when  used  in  the  mouth,  it  forms  an 
astringent  membrane  which  seals  and  protects  from  any 
infection.  The  foi-mation  of  this  preparation  is  similar 
to  surgeons'  collodion.  It  holds  from  twenty-four  to 
forty-eight  hours  and  gives  the  longest  period  of  mouth 
medication  known.  We  know  that  the  surgeons  of  today 
are  depending  more  and  more  upon  iodine  for  steriliza- 
tion.   This  "dressing"  gives  us  the  constant  penetrating 


Treatment  of  Pyoerhea  Ax.veol.aris.  267 

effect  of  this  drug.  Even  thoiigli  it  had  no  antiseptic 
properties,  the  astringent  effect  upon  the  gums  and  the 
sealing  of  the  gums  to  the  teeth,  would  make  it  of  great 
advantage. 

Many  experiments  have  been  performed  outside  of 
the  mouth  under  all  conditions  but  so  far,  we  have  been 
unable  to  effect  this  peculiar  formation  outside  of  the 
mouth. 

The  experiment  may  be  tried  of  placing  No.  1  on  a 
dried  section  of  the  gum  and  the  No.  2  over  it ;  no  combi- 
nation takes  place.  Let  the  patient  spit  and  the  moment 
the  saliva  comes  in  contact  with  the  preparation,  a  mem- 
brane is  formed  over  the  coated  surface.  Under  twenty- 
four  hours  it  is  impossible  to  remove  the  formation  from 
the  gums;  after  this  time,  it  loosens  and  comes  off  in 
small  pieces,  resembling  rubber  dam.  Instead  of  exces- 
sive hemorrhage  from  the  operation,  we  have  just  the 
minimum  amount. 

Outside  of  the  mouth,  on  the  hand,  or  anywhere, 
the  preparations  are  put  on  in  the  same  manner  and 
covered  with  saliva,  under  any  and  all  conditions,  but  no 
formation  takes  place.    "\^^iy? 

DIRECTIONS    FOR    POST    OPERATWE    DRESSING: 

The  Applicators 

The  applicators  recommended  are  made  by  dipping  the 
end  of  wood  tooth  picks  into    Sandarac   Varnish,    and 


^^   ^  / 


^ 


Fig.  43. 


268  Peactical  Pyoeehea  Alveolaeis. 

twisting  a  few  strands  of  dry  cotton  about  the  end,  these 
making  a  secure  and  convenient  swab  for  painting  the 
gums.  Several  hundred  of  these  can  be  made  in  a  few 
moments  by  your  assistant,  to  be  thrown  away  as  used. 
It  is  absolutely  essential  that  a  separate  applicator  be 
used  for  applying  No.  1  and  No.  2  preparations. 

NapMns  for  Drying  the  Gums 

The  application  is  greatly  simplified  by  the  use  of 
small  doilies  which  can  be  thrown  away.  These  are  in- 
expensive and  used  in  all  treatments  about  the  mouth. 
Buy  from  3^our  dry  goods  store,  a  bolt  of  English  long 
cloth,  costing  about  $1.00.  Mark  otf  the  stop  of  bolt  into 
squares  about  3x5  inches,  some  longer,  some  smaller. 
Your  printer  will,  with  a  few  strokes  of  his  cutter,  con- 
vert the  bolt  into  several  thousand  doilies.  These  should 
be  sterilized  and  kept  under  cover  ready  for  use. 

Technique  of  Applying  Dressing. 

Immediately  after  instrumentation  and  irrigation, 
the  mouth  is  dressed  by  drying  sections  of  the  gums  witli 
the  aseptic  napkins,  which  should  be  heJd  so  as  to  pro- 
tect the  lips  and  cheek  while  applying  with  applicator 
a  coat  of  No.  1  pyorrhea  treatment,  giving  a  moment 
for  absorption;  then  freely  paint  over  No.  1  with  No.  2 
letting  it  flow  around  and  between  the  teeth;  when  the 
napkin  is  removed  and  the  saliva  comes  in  contact  with 
the  medicated  gum,  the  combination  of  these  two  prep- 
arations forms  a  membranous  coating  or  dressing  simi- 
lar to  that  produced  by  collodion  as  used  by  surgeons. 

As  each  section  is  treated,  have  patient  rinse  mouth 
with  dental  mouth  wash.  Tfhis  at  once  removes  the  dis- 
agreoa1)le  taste  and  puckering  of  the  y)yorrhea  treatment. 
Anothei-  section  is  dried  and  treated  in  tlie  same  way 
until  all  tlic  affected  teeth  and  gums'  are  sealed.  It  is 
better  to  treat  the  u])por  jaw  first.    It  is  not  necessary  to 


Treatment  op  Pyorehea  Alveolaeis.  269 

have  dressing  extend  more  tliau  1-4  in.  from  gum  margin. 
Be  careful  not  to  seal  the  ducts  of  Whorton  and  Steno,  as 
this  would  cause  a  disagreeable  swelling  of  the  glands. 

The  benefits  of  the  iodine  contained  therein,  we  all 
know.  The  inflammation  is  deep  seated,  and  iodine  is  the 
one  agent  that  will  penetrate.  The  astringent  effect  is 
produced  by  the  tannin.  This  dressing  draws  the  gums 
to  the  teeth;  food,  saliva,  and  toxic  products  are  thus 
excluded.  The  blood-clot  in  pockets  is  protected  until 
organized  into  new  tissue. 

This  dressing  is  not  to  be  removed  for  24  hours. 
See  the  patient  regularly  every  day,  removing  the  mem- 
branous or  leathery  coating  of  the  day  before  from  the 
gums  by  a  gentle  massage  with  a  soft  tooth-brush 
moistened  in  hot  water;  the  mouth  is  sprayed  with  mouth 
wash,  and  the  dressing  of  No.  1  and  2  is  again  applied. 
After  a  week  of  treatment  it  is  not  always  necessary 
to  use  the  No.  1  as  the  septic  condition  is  under  control, 
and  the  subsequent  api)lications  may  be  of  the  No.  2 
alone. 

Sometimes,  when  an  excess  of  these  preparations  is 
used  on  the  gums,  blisters  similar  to  the  so-called  ''fever 
blisters,"  appear  in  the  mouth.  When  this  condition 
arises,  suspend  all  applications  for  a  few  days,  until  the 
condition  disappears. 

The  patient's  name  is  engraved  on  his  tooth  brush 
using  a  small  bur  in  the  dental  engine,  afterwards  tracing 
with  ink.  The  office  assistant  keeps  these  brushes  in 
alphabetical  order  in  a  small  formaldehyde  sterilizer. 

At  each  sitting  or  treatment  the  brush  is  softened  in 
warm  water  and  the  teeth  brushed  correctly,  as  described 
in  the  chapter  on  ''Brushing  the  Teeth";  this  removes 
the  pyorrhea  "dressing."  I  have  always  found  it  the  best 
policy  to  brush  the  teeth  myself,  having  the  patient  hold  a 
mirrow  so  that  he  can  acquire  the  proper  idea  of  using 
his  brush.  A  strand  of  flat  floss  silk  saturated  with 
dentrifice,  is  then  run  l)etween  the  teeth  and  the  mouth 


270  Practical  Pyoekhea  Alveolaeis. 

is  sprayed  out  with  dental  mouth  wash.  The  same  pro- 
cess of  dressing  is  made  again  and  the  patient  dismissed 
for  from  twenty-four  to  forty-eight  hours. 

After  the  patient  has  been  treated  about  a  week  or 
ten  days,  he  brushes  his  teeth  before  me  at  each  sitting 
and  in  this  manner  he  is  compelled  to  get  a  good  idea 
of  the  technique  of  brushing  his  teeth.  It  is  sometimes 
necessary  to  take  the  patient's  hand  and  guide  him  into 
brushing  correctly.  After  being  taught  in  this  manner, 
if  the  patient  comes  up  in  the  future  with  case  of  oral 
sepsis,  no  one  is  to  blame  but  the  patient,  himself. 

After  treating  the  patient  in  this  way  from  two  to 
four  weeks,  and  when  I  am  fully  satisfied  that  the  neces- 
sary tissues  has  formed  to  resist  the  force  of  mastica- 
tion, and  all  signs  of  inflammation  have  subsided,  several 
hours  are  spent  in  polishing  the  teeth.  Sometimes,  I  am 
surprised  to  find  that  so  much  tartar  -has  escaped  my 
notice  and  every  bit  of  it  will  be  shown  up  by  "AA 
Pyorrhea  Treatment  Nos.  1  and  2."  I  now  turn  my  at- 
tention to  this  and  every  scale  of  accumulation  is  re- 
moved with  the  scalers,  the  porte  polisher  or  the  polish- 
ing wheel. 

This  "treatment"  on  account  of  its  standing  qualities 
is  not  for  the  lazy  dentist,  but  in  the  hands  of  a  careful 
man  gives  the  greatest  opportunities  for  making  the 
mouth  perfectly  clean  and  for  instructing  the  patient  in 
the  proper  keeping  of  his  mouth.  Its  use  has  proved 
gratifying  both  to  the  patient  and  ourselves. 

Before  dismissing  our  pyorrhea  patients,  we  must 
have  them  understand  that  where  the  gum  is  receded 
and  the  dentine  is  exposed,  tartar  is  more  readily  collec- 
ted and  that  these  surfaces  must  be  kept  free  from  all 
accumulation.  For  this  reason,  these  patients  are  dis- 
missed only  on  probation  and  they  are  instructed  to  re- 
turn in  a  month  for  inspection,  when  they  are  again 
taken  through  the  "tooth  brush  drill".  We  endeavor 
to  persuade  all  the  resident  patients  to  take  up  our  sys- 


Treatment  of  Pyoerhea  Alveolaris.  271 

tern  of  monthly  prophylaxis  either  under  our  own  care 
or  that  of  the  dental  nurse. 

"We  have  under  observation,  cases  treated  from  ten 
to  fifteen  years  ago  who,  before  treatment,  had  been  ad- 
vised that  extraction  was  the  only  thing  that  would  re- 
lieve them;  but  they  have  never  lost  their  teeth.  Some 
of  these  cases  were  in  such  a  serious  condition  that  a 
continued  neglect  of  the  mouth  condition  would  probably 
have  resulted  in  death  from  septiccemia. 

An  interesting  case  in  the  author's'  experience  was 
that  of  a  woman  who  had  suffered  for  several  months 
with  very  severe  pains  in  the  head;  her  physicians  had 
been  unable  to  afford  any  relief.  The  surgeons  had  ad- 
vised that  an  operation  be  performed  on  the  trifacial 
nerve.  Being  called  in  as  a  consultant,  I  found  a  severe 
case  of  pyorrhea  and  by  treating  this  for  a  few  days  was 
able  to  give  the  patient  almost  complete  relief  from  pain. 

Many  cases  of  interest  like  the  above  are  contained 
in  my  records  but  I  do  not  feel  that  there  is  room  for 
them  in  a  work  of  this  kind. 


CHAPTEE     XXX. 
TREATMENT— CONTINUED. 

TREATMENT  OF   MEEEITT,   PATTEESON,   SAEEAZIN,   DUNLOP, 
LUNDY  AND   FLETCHER. 

Report  of  an  Interesting  Case  of  Pyorrhea  and  the 
Treatment  Employed.    By  Dr.  A.  H.  Merritt,  New  York. 

(Dr.  Merritt,  at  my  request,  wrote  me  this  description 
of  a  pyorrhea  case  in  a  patient  18  years  of  age,  stating 
that  it  is  the  youngest  patient  in  all  his  experience,  with 
so  advanced  a  case.  The  radiographs  of  this  case  were 
made  by  Dr.  George  M.  MacKee.) 

''This  case  I  am  seeing  for  the  last  time  on  June  21st. 
The  gums  have  already  resumed  normal  color,  the  dis- 
charge of  pus  which  was  enormous,  has  entirely  ceased, 
the  teeth  are  markedly  more  firm  and  except  for  slight 
sensitiveness  to  thermal  shock,  perfectly  comfortable, 
though  the  patient  was  in  constant  pain  all  about  the 
gums,  with  a  calcic  abscess  on  gums  over  one  molar  when 
treatment  was  commenced  in  Ai)ril.  Treatment  to  date 
has  been  entirely  local,  except  the  administration  of 
calomel  and  sodium  phosphate  for  constipation.  The 
local  treatment  consisted  of  a  very  thorough  scaling  of 
the  root  of  each  tooth  with  scalers  made  from  my  own 
design,  finishing  in  some  instances  with  fine  files,  with 
these  latter  the  edge  of  the  alveolar  plates,  and  where 
necessary  smoothing  off  ragged  edges.  This  was  fol- 
lowed each  time  by  the  application  of  weak  solution  of 
tincture  of  iodine  (85  to  50^/r)  with  careful  pro])hylactic 
treatments. 

''All  weakened  teeth  were  ground  off  so  as  to  relieve 
them  from  undue  stress.  The  patient  was  carefully 
instructed  in  the  home  care  of  her  teeth,  proper  brush 
provided  and  instructions  given  in  its  use  (two  minutes 
each  time,  four  times  daily,  straight  up  and  down  over 


Treatment  of  Pyorrhea  Alveolaris.  273 

all  tlie  gums).  Tins  briefly  outlines  the  treatment  I  fol- 
low in  all  such  cases  with  most  gratifying  results.  This 
particular  case  was  exhibited  at  a  public  clinic  before 
treatment    was    begun    and   will    again    be    shown    next 


Fio.  44.    Radiographs  of  Dr.  Merritt's  Case. 

autumn  to  the  same  men  to  confirm  my  experience  in 
such  cases, 

"To  me  it  seems  that  there  is  too  much  theory  in  the 


274  Practical  Pyoerhea  Alveolaris. 

treatment  of  all  pyorrhea  cases,  making  it  appear  to  be 
very  difficult,  when  in  reality  it  is  comparatively  simple." 

TREATMENT  OF  PYORRHEA  ALVEOLARIS 
BY  JOHN  DEANS  PATTERSON". 

(From  Johnson's  "Operative  Dentistry,"  by  permission  of  P.  Blakis- 
ton's  Son  &  Co.) 

"In  beginning  the  operation  of  scaling,  it  is  wise  to 
select  only  that  number  of  teeth  for  one  operation  which 
can  be  entirely  finished  at  one  sitting.  If  the  disease  is 
in  the  incipient  stages,  frequently  a  number  of  teeth  can 
be  treated;  if  the  condition  is  in  the  advanced  stages, 
from  one  to  four  should  be  the  limit.  ^  In  all  cases  each 
operation  should  be  limited  to  an  hour,  for,  in  the  first 
place,  whatever  the  means  used  for  obtunding,  the  opera- 
tion is  more  or  less  painful;  the  teeth  operated  upon  are 
also  left  in  a  condition  acutely  sensitive  to  thermal 
changes,  and  if  many  teeth  are  treated  at  one  sitting,  the 
discomfort  is  distressing  for  many  days  on  this  account ; 
so  it  is  surely  best  to  confine  this  discomfort  and  the 
painful  scaling  to  a  limited  time  and  a  limited  area  to 
prevent  accumulated  discomfort  in  cervical  territory  on 
account  of  thermal  irritation,  and  to  prevent  shock  from 
the  unavoidable  pain  of  the  operation.  With  the  correct 
diagnosis  as  to  the  extent  of  the  disease  and  the  selection 
of  the  suitable  instruments,  there  must  be  a  determina- 
tion upon  the  part  of  the  operator  that  the  roots  selected 
to  be  operated  upon  at  any  sitting  shall  be  entirely  freed 
from  irritating  deposits  and  the  surfaces  left  in  a  con- 
dition to  encourage  the  new  tissue  of  repair  to  form. 
The  surgical  part  is  not  complete  upon  the  removal  of 
deposits,  but  after  that  these  surfaces  should  be 
smoothed  and  polished  as  perfectly  as  may  be.  About 
the  crowns  and  the  cervix  of  the  tooth  engine  instru- 
ments with  brushes,  strips,  rubber  cones,  etc.,  of  a  great 
variety  of  shapes,  are  applicable ;  beyond  the  gum  margin 
hand  instruments  must  be  used.    The  various  wood  and 


Treatment  of  Pyoeehea  Alveolaeis.  275 

other  points,  held  in  suitable  porte-polisher  and  charged 
with  an  abrasive,  must  reach  all  possible  surfaces. 
Experience  has  taught  that  the  time  spent  in  smoothing 
the  roots  is  well  worth  the  endeavor,  for  the  rapidity  and 
permanency  of  recovery  is  greatly  enhanced,  and  the 
operation  cannot  be  considered  completed  until  as  much 
time  is  given  to  the  polishing  as  to  the  removal  of 
deposits. 

''The  polishing  concluded,  then  comes  the  removal  of 
all  loosened  detritus  with  the  hot  water  used  in  a  strong 
force  syringe  with  slender  special  points  which  will  reach 
well  down  into  the  pockets ;  these  points  are  best  made 
of  silver  or  German  silver,  and  can  be  fashioned  by  any 
instrument  maker. 

''The  surfaces  from  which  the  coating  of  deposit  is 
removed  are  a  source  of  great  discomfort  to  the  patient 
in  whatever  manner  they  may  be  treated ;  the  writer  uses 
a  10  per  cent,  solution  of  silver  nitrate,  which,  as  is  well 
known,  renders  those  surfaces  much  less  painful.  AVhen 
the  discoloration  is  not  an  objection,  a  saturated  solution 
of  the  silver  nitrate  brings  results  not  secured  by  any 
other  drugs.  The  10  per  cent,  solution  is  just  short  of 
the  discoloring  strength.  In  using  the  silver  solution  the 
parts  should  be  protected  from  saliva  for  a  few  seconds. 
After  this  treatment,  all  inflamed  and  diseased  gum 
tissue  should  be  bathed  with  drugs  or  combinations  of 
drugs  which  stimulate  absorp'tion,  act  as  counter-irri- 
tants and  obtuncl  irritated  surfaces. 

"If  the  operation  has  been  well  done,  it  is  inadvisable 
to  disturb  the  pockets,  which  are  soon  filled  with  the 
plasma,  out  of  which  repair  comes.  The  very  common 
practice  of  frequent  probing  and  medicating  is  strongly 
condemned." 

the  sarrazin  treatment. 

Dr.  J.  J.  Sarrazin,  of  New  Orleans,  La.,  has  worked 
out  an  elaborate  system  of  prophylaxis  and  j^yorrhea 


276  Peactical  Pyoeehea  Alveolaris. 

treatment.  The  Dental  Cosmos  (May,  1910)  gives  Ms 
system  of  treating  pyorrlieal  conditions. 

From  this  article  I  quote: 

''There  are  two  ways  of  handling  a  jaw  which  is 
affected  generally  by  the  disease.  One  is  to  begin  at  the 
most  posterior  tooth  on  one  side  and  stop  at  the  median 
line;  then  continue  by  starting  at  the  most  posterior 
tooth  on  the  opposite  side  and  again  come  to  the  median 
line.  This  has  the  advantage  of  allowing  time  for  molars 
on  one  side  of  the  mouth  to  lose  much  of  their  tenderness 
before  the  molars  on  the  opposite  sides  are  made  too 
sore  for  mastication.  The  second  way  will  grow  out  of 
aggravated  conditions  in  some  localities,  in  which 
instances  the  operator  will  see  that  such  places  must  be 
operated  upon  at  the  start,  so  that  ample  time  may  elapse 
to  watch  their  behavior  while  the  surgical  treatment  is 
being  continued  elsewhere. 

"I  am  partial  to  pull-cut  instruments  for  accomplish- 
ing just  exactly  what  is  wanted  on  roots.  On  a  smaller 
scale,  the  motion  of  such  instruments  should  be  more 
like  that  of  a  vulcanite  scraper  on  a  plate,  and  still  more 
similar  to  that  of  a  pencil  eraser  on  paper,  the  push 
stroke  being  much  lighter,  and  not  like  that  of  a  plane 
on  wood.  Instrument  points  should  be  so  directed  as  to 
operate  on  only  a  small  speck  of  a  root  surface  at  a  time, 
making  sure  of  having  completely  scaled  that  point 
before  ])assing  to  an  adjacent  spot  either  horizontally  or 
vertically.  Such  operating  should  be  done  not  only  where 
well-defined  pockets  exist,  but  also  wherever  soft  tissues 
fail  to  closely  hug  and  adhere  to  cementum.  If  the 
alveolar  tissue  be  affected  beyond,  diseased  portions 
surely  lead  to  it,  if  they  are  ])roperly  followed.  On  the 
otiier  hand,  soft  tissue  should  be  respected  wherever  it  is 
attached  to  tlie  pericementum,  but  instruments  should 
reach  quite  to  the  lines  of  such  attachments  in  every 
direction. 

''If  operations  have  been  severe,  wounds  should  be 


Treatment  of  Pyoekhea  Alveolaris.  277 

frequently  irrigated,  just  as  is  practiced  in  general  sur- 
gery, until  such  a  time  as  the  tissue  shows  a  proper 
tendency  to  heal.  Bismuth  paste  following  such  irriga- 
tion acts  very  favorably,  at  the  same  time  warding  off 
the  danger  of  impaction  of  fermentative  material. 

''However  thorough  the  scaling  of  a  single  or  multi^ 
rooted  tooth  may  have  been,  there  is  safety  in  making 
use  immediately  after  operating,  of  a  drug  capable  of 
dissolving  calcareous  particles.  Wherever  the  alveolus 
has  been  seriously  affected,  greater  reliance  may  prob- 
ably be  placed  on  50  per  cent,  sulfuric  acid  in  glycerin, 
because  long  clinical  experience  indicates  its  marked 
action  on  hard  tissues,  with  a  reduced  irritation  to 
soft  ones." 

TREATMENT   OF   PYORRHEA   WITH   ETHYL   BORATE   GAS 
BY   DR.    W"M.    F.    DUNLOP,   NEW    YORK. 

"The  Dunlop  Treatment  consists  primarily  in  the 
introduction  of  oxygen  into  the  tissues  and  circulation, 
and  stimulating  nerve  control.  It  had  long  been  recog- 
nized that  oxygen  could  probably  cure  pyorrhea,  and 
many  experiments  have  been  made  with  a  view  to  forc- 
ing the  gas  directly  into  the  gums.  These  attempts  failed 
because  pure  oxygen  unfortunately  burns  up  live  tissue 
as  well  as  dead  tissue. 

''I  use  the  ethyl  borate  gas  under  pressure,  which  is 
introduced  by  means  of  a  small  needle  at  the  free  margin 
of  the  affected  gums.  The  features  of  this  gas  as  against 
pure  oxygen  are :  first,  that  it  destroys  only  dead  matter, 
by  stimulating  the  circulation.  The  live  tissues  are  not 
attacked  by  the  gas  at  all.  Secondly,  the  gas  travels 
through  the  pus  passage  and  ramifications  about  the 
roots  and  along  the  jaw,  not  ]>y  ]iressure,  but  by  its  own 
natural  affinity  for  pus  and  dead  matter. 

"Wben  a  case  of  pyorrhea  has  been  cured  and  the 
passages  have  been  emptied  of  microbes  and  putrifying 
secretions,  tlie  gums  refuse  to  take  the  gas. 


278  Peactical  Pyorehea  Alveolaris. 

''I  belive  that  this  gas  cures  by  virtue  of  its  burning 
up  dead  matter  and  its  stimulation  of  blood  circulation. 
Eecent  experiments  suggest  that  gas  gets  results  as  a 
germicide  by  increased  circulation. 

"Before  applying  the  gas  it  is  first  necessary  to 
remove  the  original  cause  of  the  disease,  viz. :  the  local 
irritation. 

"After  the  operation  is  completed  we  are  ready  for 
the  vapor  treatment;  the  gums  are  sprayed  and  all  the 
pockets  fully  impregnated  with  the  antiseptic  from  the 
machine.  Before  the  patient  is  discharged,  place  a  strip 
of  the  pocket  packer  over  the  free  margins  of  the  gums, 
pressed  firmly  in  between  the  teeth,  both  lingual  and  buc- 
cal. This  must  remain  in  place  in  order  to  keep  the  tender 
surfaces  of  the  gum  free  from  contact  with  the  secretions 
of  the  mouth  and  any  other  foreign  substance.  The 
deeper  pockets  are  to  have  a  small  portion  of  the  pocket 
packer  forced  up  into  them,  and  a  warm  instrument 
passed  into  it  while  in  position.  This  will  hermetically 
seal  the  space  or  pocket. 

"When  the  patient  presents  himself  for  the  second 
sitting,  the  pocket  packer  is  removed,  the  gums  thor- 
oughly sprayed  with  the  machine,  the  same  being 
properly  charged  to  throw  this  spray  without  the  use  of 
the  needle.  You  next  put  the  needle  on  the  tube.  Open- 
ing the  valve  on  the  machine  it  will  be  found  that  a  dry 
gas  or  vapor  escapes  from  the  needle.  In  passing  the 
needle  around  the  gingival  margin,  or  perhaps  slightly 
under  it  in  some  cases,  it  will  be  seen  that  the  gas  is 
taken  up  by  the  inflamed  ducts,  and  it  will  pass  up 
through  the  gums,  forming  little  stringers,  and  will  only 
stop  when  they  seem  to  reach  their  destination  in  the 
glands  themselves.  This  action  is  visible  to  the  naked 
eye. 

"Generally,  where  this  inflamation  is  pronounced, 
there  will  be  a  cyanotic  condition  of  the  gums,  caused  by 
improper  elimination,  or  a  lack  of  oxygen.     This  gas 


Treatment  of  Pyoerhea  Alveolaris.  279 

being  carried  into  the  tissues  is  robbed  of  its  oxygen, 
and  the  solids  are  precipitated  into  the  tissues,  causing 
an  inflammation,  which  brings  blood  to  the  parts,  the 
same  as  any  other  irritation  will  cause  an  influx  of  blood, 
but  with  the  difference  that  in  this  case  the  tissues  are 
thoroughly  oxygenated  and  circulation  is  re-established, 
the  cyanotic  condition  disappearing.  The  tissues  produc- 
ing cells  are  stimulated  to  action,  and  constantly  fed  by 
the  application  of  this  gas  until  they  will  receive  no 
more.  If  this  is  kept  up  at  intervals — with  a  few  days 
apart— and  the  surfaces  kept  clean,  we  have  not  only  the 
rebuilding  of  this  lost  material,  but  there  is  a  re-attach- 
ment of  the  root  of  the  tooth  to  the  alveolar  dental  mem- 
brane and  a  consequent  cure." 

The  above  article  on  the  Dunlop  method  is  given  for 
the  reason  that  it  is  entirely  a  new  departure  in  our 
methods  of  treating  pyorrhea.  The  author  has  endeav- 
ored to  secure  more  data  as  to  its  relative  efficiency,  but 
it  has  not  been  on  the  market  long  enough  to  gather  any 
definite  information. 

There  are  many  who  claim  that  deep  infection  in  the 
alveolar  process  can  be  relieved  by  its  use.  However, 
there  is  some  opposition  developed  against  it  as  voiced 
by  the  following  quotation  from  Talbot,  in  his  '' Inter- 
stitial Gingivitis  and  Pyorrhea  Alveolaris." 

''Within  the  past  year  a  machine  has  been  placed 
upon  the  market  for  the  supposed  purpose  of  forcing 
oxygen  through  the  tissues  in  the  treatment  of  this  dis- 
ease. I  have  watched  this  process  of  treatment  'with 
fear  and  trembling'  since  the  method  of  application 
forces  the  pus  germs  through  the  inflamed  alveolar  pro- 
cess. Why  infection  does  not  occur  is  a  mystery.  This 
method  of  applying  drugs  and  forcing  pus  germs  into  the 
tissues  without  infection  is  a  strong  point  in  favor  of 
the  non-infectious  theory  of  interstitial  gingivitis." 


280  Peactical  Pyokrhea  Alveolaris. 

treatment  of  dr.  e.  a.  lundy,  of  los  angeles,  californl\. 

''The  majority  of  cases  preseutiiig  are  simply  an  oral 
manifestation  of  a  systemic  clistnrbance.  For  twelve 
years  past  my  treatment  lias  been  both  from  a  local  and 
systemic  standpoint,  and  results  obtained  have  been  far 
more  satisfactory. 

"My  systemic  treatment  varies  in  individual  cases, 
bnt  is  arranged  with  a  view  to  the  establishment  of  a 
normal  elimination  and  assimilation.  I  find  in  the 
majority  of  cases  that  constipation  is  present  with  resul- 
tant autointoxication,  and  my  treatment  is  with  a  view 
to  overcoming  such  conditions.  My  first  efforts  may  be 
by  internal  medication,  but  later  I  resort  to  that  of  a 
proper  dietary,  in  which  I  try  and  prescribe  such  foods 
as  are  compatible  and  require  chewing,  I  also  try  and 
prescribe  a  non-uric  acid  dietary. 

"My  favorite  remedies  for  local  treatment  at  present 
are  Dr.  Sens  solution  of  iodin  and  i^otassium  iodide,  one 
part  to  water  four  hundred  parts,  making  practically  a 
one  per  cent,  solution." 

Fletcher's  method  of  removing  diseased  alveolus. 

The  following  quotation  is  taken  from  "Alveolitis  — 
the  Disease  of  Which  Pyorrhea  Alveolaris  is  One  Stage," 
by  Dr.  M.  H.  Fletcher,  printed  in  the  Dental  Summ.ayy. 

"To  operate  in  any  of  these  cases  is  surgery  and  not 
dentistry,  so  that  the  stomatologist  also  needs  to  be  skill- 
ful in  operative  surgery  to  a  degree  Avhich  gives  him 
suitable  knowledge  and  confidence  in  himself  to  handle 
a  |);iti(']it  undergoing  the  removal  of  part  of  the  alveolar 
])rocess  eitlier  above  or  lielow.  Fui'tlier,  tlie  oyx'i-ator 
should  l)e  so  in  touch  with  this  patient  and  the  extent  of 
tile  opei'aiion  as  to  know  wlicllier  ilic  opci-alion  slionid 
be  perfonned  under  local  or  general  anestii(^sia,  and 
whether  it  should  all  l)e  done  at  once  or  at  intervals  of  a 
few   days   or   weeks   for   general    and    systemic   coinpli- 


4 


u 


H 


A 


g 


f 


Fig.  45.    Fletcher's  Set  of  Bone  Curettes  and  Alveolar  Burs 

FOR  Cutting  Away  Dead  and  Diseased  Bone.     Not 

Intended  for  Removing  Deposits. 


282  Pbactical  Pyorrhea  Alveolaris. 

cations  from  secondary  and  acute  infection  may  occur 
at  any  time. 

''The  curettes,  or  hand  instruments  are  all  of  the  hoe 
and  hatchet  type,  varying  only  in  size  of  blade  and  length 
and  shape  of  shank.  The  attempt  is  made  by  these  varia- 
tions to  reach  any  extended  tract  of  necrosis.  The 
necrosed  portions  are  usually  friable — that  is,  in  the 
state  of  osteoporosis — and  can  easily  be  cut  away  with 
the  curettes;  but  certain  phases  of  the  disease  and  certain 
kinds  of  infection  often  result  in  osteosclerosis ;  that  is, 
hardened  or  eburnated  bone,  on  which  the  curettes  make 
little  headway.  For  cutting  these  hardened  bones  I  have 
made  some  extra  long  bone-cutting  burs,  both  for  the 
straight  and  right  angle  hand-pieces.  The  contra-angle 
seems  to  be  more  suited  to  the  work,  however,  than  the 
right  angle.  The  burs  for  the  contra-angle  will  reach  all 
cases  in  the  lower  jaw  and  most  of  the  upper,  but  a  bur 
two  and  one-half  to  three  inches  long — that  is,  one  long 
enough  to  reach  to  and  into  the  antrum — is  often  neces- 
sary for  the  upper  jaw. 

"The  laws  of  regeneration  do  not  permit  of  complete 
healing  of  bone  tissue  inside  of  several  weeks  at  the 
shortest,  and  often  require  several  months,  so  that 
patience  and  careful  watching  are  necessary  on  the  part 
of  both  patient  and  doctor.  One  patient  now  on  my  list  for 
nearly  a  year,  who  would  not  submit  to  a  radical  removal 
of  cancellous  bone  in  the  superior  maxillary,  has  sub- 
mitted to  a  small  amount  of  removal  from  time  to  time, 
and  is  gradually  recovering  under  two  dressing  treat- 
ments a  week.  This  case,  however,  was  the  result  of  a 
dental  abscess  arising  at  the  apex  of  a  superior  lateral 
which  had  discharged  into  floor  of  the  nose. 

''After  curetting  and  burring  have  been  done,  the 
cavities  should  be  washed  out  with  a  warm  antiseptic  solu- 
tion to  remove  the  cuttings.  The  blood  shouhl  be  allowed 
to  clot  in  the  cavity.  My  plan  is  to  be  careful  not  to  dis- 
turb the  blood  clot  as  long  as  it  remains  aseptic.    If  there 


Treatment  of  Pyorrhea  Alveolaris.  283 

is  a  tendency  for  pus  to  form,  the  wound  should  he 
washed  out  every  one,  two,  or  three  days,  according  to 
conditions,  and,  if  pus  continues  after  ten  days,  a  second, 
third,  or  even  more  attempts  must  be  made  to  remove  the 
offending'  material. 

"Aseptic  blood  clot  is  Nature's  'false  work'  or 
scaffolding  on  and  into  which  she  builds  all  new  tissues, 
no  matter  of  what  kind.  The  less  the  healthy  clot  is 
disturbed,  the  more  prompt  is  the  repair.  In  the  blood 
clot  is  formed  the  granulation  tissue  of  repair,  which  is 
the  second  stage  of  the  building  of  new  tissues.  Any  dis- 
turbance to  these  granules  is  also  a  hindrance  to  repair; 
hence  packing  is  seldom  called  for. 

''If  I  have  suggested  anything  new  or  valuable,  T 
believe  it  is  the  necessity  of  either  curetting  or  burring 
about  all  teeth  where  the  disease  is  found,  and  of  more 
thorough  removal,  if  the  disease  is  deep  seated." 


CHAPTEE     XXXI. 
TREATMENT— CONTINUED. 

A    TECHNICAL    DESCKIPTIOlSr    OF    THE    SURGEEY    OP    THE    EOOT 

SURFACE  AND  THE  INSTRUMENTS  MOST  USEFUL 

IN  ACHIEVING  IT. 

BY  THOMAS  B.    HARTZELL,  D.  M.D.,   M.  D.,    MINNEAPOLIS. 

'^In  undertaking  to  write  an  article  descriptive  of  the 
technical  procedure,  which  must  be  observed  in  success- 
fully treating  pyorrhea,  I  realize  that  I  am  undertaking 
a  very  difficult  task.  To  portray  in  words  or  visualize 
technical  procedure,  is  always  difficult,  but  by  the  help 
of  word  pictures  and  illustrations  together,  I  hope  to  be 
able  to  convey  a  comprehensive  idea  of  the  operation. 


''The  necessity  for  root  surface  surgery  is  now  so 
thoroughly  understood  that  we  need  not  discuss  that 
phase  of  the  question  at  all,  though  it  will  be  wise  to 
discuss  the  histology  of  the  root  surface  in  order  that  we 
may  have  a  reasonably  clear  idea  of  the  necessity  for  the 
operation,  and  also  that  we  may  know  how  much  of  the 
root  surface  we  should  remove  and  where  the  cutting 
should  stop. 

''The  root  is  suspended  in  its  socket,  as  we  all  know, 
by  fibres  of  sharpey ;  these  fibres  originate  in  the  alveolar 
process.  When  the  bone  of  the  process  is  lost  from  any 
cause  whatever,  then  these  fibres  hang  dead  upon  the  root 
surface  and  their  decaying  remains  afford  culture  media 
in  which  micro-organisms  may  rapidly  grow  and  accu- 
mulate. The  root  surface  is,  therefore,  uneven  and  pitted 
with  thousands  of  small  depressions.  These  depressions 
were  occupied  by  fibre  ends,  and  offer  to  the  eye,  when 
ol)served  under  tho  microscopo,  a  honey-comb  like 
surface. 


Treatment  op  Pyoerhea  Alveolaris.  285 

"The  operation  on  the  root  surface  may  involve  two 
things:  first,  the  removal  of  any  calculus  deposited 
upon  the  root  surface;  and,  second,  the  removal  of  the 
pitted  root  surface  itself.  Observing  the  structure  of  the 
root,  from  the  pulp  chamber  outwardly,  we  note  first 
that  dental  tubuli  form  the  great  bulk  of  the  root.  Just 
external  to  the  tubuli,  we  may  note  a  layer  of  typical 
bone  which  contains  thousands  upon  thousands  of  lacunae 
connected  by  branching  canaliculi.  Approaching  more 
nearly  to  the  surface  of  the  cementum,  we  see  that  the 
lacunae  and  canaliculi  become  fewer  and  fewer  until  the 
root  surface  is  almost  reached,  at  which  point  we  note  a 
narrow  zone  of  bone  which  contains  neither  lacunae  nor 
canaliculi.  This  dense  layer  is  not  clearly  defined  as 
something  that  could  be  stripped  up  and  peeled  off,  but, 
nevertheless,  nature  seems  to  have  deposited  this  thin 
layer  of  hardened  bony  material  as  a  foundation  into 
which  the  Sharpey's  fibres  insert  to  form  the  suspensory 
ligament  which  is  the  sling  or  stirrup  by  which  the  tooth 
rides  in  its  socket. 

•'The  object  of  skinning  the  root  surface  is  to  rid  that 
root  surface  of  its  bacterial  holding  power.  Therefore, 
the  amount  of  root  surface  which  may  be  cut  away  with 
benefit  to  the  tooth  is  that  portion  external  to  this  dense 
layer  which  was  created  to  support  the  fibre  ends.  And, 
because  of  the  fact  that  this  dense  layer  is  very  thin,  one 
should  guard  carefully  against  cutting  enough  of  it  away 
to  open  the  bone  cells  which  are  so  plentifully  dis- 
tributed in  the  body  of  the  cementum.  Therefore,  one 
should  work  with  instruments  so  designed  as  to  make  it 
impossible  in  any  single  stroke  to  penetrate  this  hard 
layer. 

"The  instruments  should  be  so  designed  as  to  offer 
the  greatest  amount  of  steadiness  and  accuracy  of  move- 
ment. To  that  end,  it  is  desirable  that  the  cutting  bit, 
which  is  used  to  skin  off  the  porous  surface,  should  be 
flat  and  thick  and  sharpened  to  a  right  angle.    It  is  also 


286  Practical  Pyorrhea  ALVEor.ARrs. 


Fiij.  40.    The   IIartzell  Tyi'e  of 
Instruments. 


Treatment  of  Pyorrhea  Alveolaris.  287 

desirable  that  the  iustrument  should  rest  on  at  least  two 
IDoints,  rather  than  on  the  cutting  edge  alone.  If  the 
instrument's  bit  rests  upon  the  cutting  edge  and  that 
portion  of  the  shank  immediately  contiguous  to  the  cut- 
ting edge,  we  have  the  so-called  two-point  rest  instru- 
ment, which  certainly  offers  greater  security  and  accu- 
racy of  movement  than  a  razor-edged,  one-pointed 
instrument  possibly  could  afford.  The  following  is  an 
illustration  of  the  instrument  to  be  applied  to  root 
surfaces. 

''On  account  of  the  unevenness  of  the  root  surface 
and  on  account  of  its  convex  and  at  times  concave  char-' 
acter,  it  is  necessary  to  have  instruments  which  can  be 
readily  adapted  to  convex  surfaces  as  well  as  to  concave 
flat  surfaces,  in  order  to  accurately  skin  every  bit  of 
dead  membrane  pitted  surface  from  any  given  root.  This 
necessity  at  once  creates  the  demand  for  three  t^^pes  of 
plane-heads.  By  the  word  "plane-head,"  I  mean  to 
describe  the  cutting  bit  and  the  portion  of  the  shank 
immediately  contiguous  to  it,  which  makes  the  two  points 
of  contact  to  the  root,  which  must  or  should  be  in  contact 
with  the  root  surface  as  the  instrument  is  moved.  The 
plane-head,  therefore,  is  to  the  tooth's  root  plane  just 
what  that  portion  of  a  carpenter's  plane  is,  which  is 
immediateh"  in  front  of  the  cutting  bit.  It  limits  the 
depth  to  which  the  cutting  bit  must  penetrate  the  tissue, 
and,  as  stated  a  moment  ago,  we  need  three  types  of 
plane-heads  for  ordinary  tooth  root  surface  surgery: 
concave  plane-heads  to  fit  convex  root  surfaces;  convex 
plane-heads  to  fit  concave  root  surfaces;  and  flat  plane- 
heads  to  fit  concave  root  surfaces;  and  flat  plane-heads 
to  fit  flat  root  surfaces.  This  at  once  necessitates  three 
types  of  plane-heads  in  any  efficient  set  of  instruments 
for  root  surface  work.  To  that  end,  the  author  di\"ides 
the  instruments  into  three  groups  for  these  three  types 
of  surfaces. 

"The  next  necessity,  which  the  operator  feels  keenly, 


288  Practical  Pyorrhea  Alveolaris. 

is  the  need  of  different  sizes  of  instruments :  long  instru- 
ments for  deep  pockets,  medium  length  instruments  for 
medium  depth  pockets,  and  short  instruments  for  shallow 
pockets.  This  again  divides  the  instruments  into  three 
groups,  dependent  on  length  of  the  shank. 

"The  third  need  which  the  operator  is  compelled  to 
notice  is  that  in  order  to  work  far  back  in  the  mouth  with 
ease,  it  is  necessary  to  bend  the  shank  of  the  instrument 
at  an  angle  which  will  permit  him  to  reach  back  in  the 
mouth  and  up  or  down,  according  to  whether  he  is  work- 
ing on  the  upper  or  lower  jaw.  Therefore,  the  case  of 
instruments  is  again  divided  into  large  groups.  One 
groujD  of  instruments  is  intended  for  working  far  back 
in  the  mouth  and  exhibiting  such  bend  as  will  readily  per- 
mit facile  movement.  The  other  group,  which  is  more 
nearly  straight,  the  operator  can  apply  in  the  anterior 
part  of  the  mouth. 

''A  fourth  need,  which  must  be  met  in  any  given  set 
of  instruments,  is  to  have  a  sufficient  number  of  pairs  of 
instruments  to  enable  the  operator  to  apply  his  plane- 
head  to  every  aspect  of  a  root,  without  changing  his 
position  in  relation  to  the  patient,  without  changing  his 
finger  rest,  and  without  flexing  his  wrist. 

''To  that  end,  the  various  types  of  instruments  are 
divided  into  families  of  eight  each.  Each  family  of  eight 
are  so  designed  as  to  enable  the  operator  to  work  upon 
eight  different  sides  of  any  single  root,  without  chang- 
ing his  initial  finger  rest  or  the  bend  of  his  wrist,  so  that 
the  whole  set  of  instruments  at  command  of  the  operator, 
whether  it  is  for  concave,  convex,  or  flat  surfaces,  or 
whether  it  is  an  instrument  with  a  large  bend  for  use 
far  back  in  the  mouth,  or  an  instrument  more  nearly 
straight  for  the  anterior  part  of  the  mouth,  will  present 
a  series  of  four  pairs  of  planes  in  whatever  size,  bend 
of  the  shank  is  desired.  This  really  affords,  in  every 
group  of  eight,  four  pairs,  of  which  one  and  five  afford 
instruments  to  fit  the  mesial  and  distal  of  any  given  root; 
two  and  six  making  a  second  pair ;  number  two  designed 


Teeatment  of  Pyorrhea  Alveolaris.  289 

to  fit  the  first  right  molar  of  any  given  patient,  two  and 
six  designed  to  present  a  pair  of  blades  which  will  fit  the 
mesial  buccal  and  distal  lingual  surfaces  of  the  molar  in 
question.  Three  and  seven  of  this  group  of  eight  present 
a  pair,  which  fits  the  buccal  and  lingual  surfaces  of  a 
patient's  right  lower  molar.  Four  and  eight  constitute 
a  fourth  pair  designed  to  fit  the  distal  buccal,  and  mesial 
lingual  surfaces  of  a  right  lower  molar. 

''It  does  not  necessarily  follow  that  the  operator  need 
use  every  instrument  of  any  given  group  of  eight  to  plane 
a  lower  molar,  but  it  is  exceedingly  helpful  to  have  the 
instruments  so  planned  as  to  make  it  possible  to  approach 
at  least  eight  ditfrent  aspects  of  any  tooth  in  the  mouth, 
without  changing  finger  rest,  if  the  operator  so  desires. 

"A  fifth  essential  is  that  in  all  of  the  instruments  of 
whatever  type,  concave,  convex,  or  flat,  long,  medium,  or 
short,  for  operation  far  back  in  the  mouth  or  almost 
straight  or  slight  bend  for  operation  in  the  anterior  part 
of  the  mouth,  or  for  what  iDarticular  tooth  or  surface  an 
instrument  is  intended,  the  cutting  blade  of  the  instru- 
ment should  be  directly  in  line  with  the  center  of  the 
handle.  This  makes  every  instrument,  no  matter  what 
bend  the '  shank  may  have,  in  effect  a  straight  instru- 
ment. ' ' 


CHAP  TEE     XXXII. 

IMPLANTATIOlSr. — BIFURCATION   TEEATMENT.— EEMOVAL   OF 

PULPS.- — AMPUTATION  OF  TOOTH  EOOTS. TREATMENT 

OF  PYOEEHEAL  ABSCESS 

For  many  years  the  experimental  surgeons  in  denti- 
stry have  endeavored  to  find  some  system  whereby  lost 
teeth  could  be  replaced  in  the  jaw  by  other  human  teeth. 
Dr.  Younger  was  one  of  the  first  to  make  a  success  of 
this  operation  and  it  is  to  be  doubted  whether  his  first 
technique  has  been  improved  upon. 

Dr.  Kells  also  makes  the  practice  of  the  implantation 
of  one  missing  tooth,  but  these  are  planted  in  a  favor- 
able situation.  I  have  seen  in  his  office  a  lower  molar 
tooth  that  had  been  implanted  for  seven  or  eight  years. 

Dr.  Eobert  Good,  of  Chicago,  is  doing  a  great  deal 
of  this  work  in  pyorrhea  cases.  His  method  is  so  unique 
and  original  that  I  will  describe  it  in  detail  as  I  have 
seen  it  carried,  out  in  his  office. 

Some  years  ago,  a  travelling  man,  a  patient  of  Dr. 
Good's,  presented  himself  to  me  for  treatment  of  his 
gums.  He  stated  that  Dr.  Good  was  beginning  to  treat 
him.  His  anterior  teeth  had  all  protruded  and  had 
rotated  in  their  sockets.  At  that  time,  if  he  had  asked 
me,  I  would  have  told  him  to  have  them  all  extracted 
as  the  only  thing  to  do,  and  in  fact  if  the  case  had  been 
one  of  my  own,  I  would  have  extracted  all  the  teeth  and 
placed  a  bridge.  However,  I  gave  him  a  treatment  and 
asked  him  on  his  next  trip  here  to  stop  in  and  let  me 
see  what  Dr.  Good  had  done.  In  about  a  year  the  same 
man  presented  himself  again ;  this  time  his  teeth  in  new 
sockets  and  in  perfect  alignment  and  comparatively 
firm.  Had  I  not  seen  the  case  before,  I  could  not  have 
believed  that  this  could  have  been  done. 

Dr.  Good's  assistant  haunts  the  places  whore  teeth 
are  extracted,  hunting  for  peculiar  kind  of  teeth.     The 


Implantation  in  Pyoerhea.  291 

tooth  lie  wishes  is  that  of  an  old  person,  especially  if 
it  has  an  exotosis  on  the  end  of  the  root.  The  searcli 
has  evidently  been  successful,  for  he  had  large  jars  of 
these  kept  in  liquid  in  his  laboratory  ready  for  selection 
on  a  moment's  notice. 

Dr.  Good  seems  to  think  it  a  very  simple  matter,  if  one 
cannot  cure  a  tooth  affected  with  pyorrhea,  to  extract  the 
tooth,  clean  it  off,  deepen  the  socket,  and  force  the  tooth 
back,  secured  by  a  retainer  of  twisted  linen  or  silk  thread. 
If  the  tooth  is  out  of  line,  which  they  frequently  are  in 
pyorrhea  work,  it  is  rotated  with  one  movement  of  the 
forceps. 

However,  the  most  original  work  which  I  saw  was 
where  an  upper  molar  tooth  was  needed  for  an  attach- 
ment for  a  bridge.  A  new  socket  was  bored  at  about  the 
position  of  the  second  molar  and  a  large  cuspid  root, 
with  the  crown  cut  off,  was  driven  tight  into  place. 
Previous  to  the  insertion,  he  had  made  a  platinum  cop- 
ing so  as  not  to  disturb  the  root  when,  he  was  ready  to 
make  this  bridge. 

He  uses  no  special  instruments  other  than  a  Younger 
root  reamer.  The  canal  is  properly  filled  and  the  tooth, 
having  stood  in  a  strong  solution  of  lysol  while  the  socket 
was  being  made,  without  being  washed  off,  was  driven 
home  tight.  After  such  a  tooth  has  stood  for  some  four 
or  five  months  it  is  generally  ready  for  bridge  work. 

For  the  encouragement  (?)  of  those  who  wish  to  try 
this  for  bridge  work  in  pyorrhea  cases,  I  will  say  that  I 
have  tried  it  on  several  teeth,  but  to  this  date  I  have 
never  been  able  to  get  one  to  stick  in  a  pyorrhea  case. 

Another  method  of  replacing  pyorrhea  teeth  Avhen 
they  are  needed  for  extra  abutments  for  bridge  work  is 
by  inserting  some  device  made  of  metal ;  one  of  these  is 
made  and  sold  by  Dr.  Greenfield,  of  Wichita,  Kans.  It 
is  a  platinum  frame  work  made  in  a  circle  which  is 
inserted  into  the  jaw  to  fit  the  trefined  socket  which  has 
left  a  central  core.  This  method,  while  possibly  the  best 
one  now  in  vogue  for  attaching  teeth  to  a  bridge  at  the 


292  Practical  Pyoerhea  Alveolaeis. 

alveolus,  is  uot  so  successful  iu  pyorrliea  cases,  because 
the  alveolus,  having  been  partially  absorbed,  does  not 
give  the  proper  support. 

To  those  who  desire  to  experiment  along  this  line  is 
suggested  the  following  method,  which  has  been  tried  by 
several  of  our  j)ractitioners :  either  drill  a  new  socket  or 
use  the  old  one  and  select  a  common  wood  screw  with 
large  threads  w^hich  will  fit  the  socket  tightly.  This  hav- 
ing been  fitted  and  cut  off  to  proper  length,  is  unscrewed, 
the  impression  taken,  and  cast  in  either  tin  or  silver.  A 
hole  is  drilled  in  the  larger  end  and  the  coj^ing  fitted. 
The  cast  screw  is  then  forced  into  place  and  after  a  few 
weeks,  when  the  tissues  have  about  resumed  their  normal 
state,  the  crown  or  bridge  is  fitted  thereon. 

After  implantation,  by  the  use  of  A  A  Pyorrhea 
Treatment,  we  are  enabled  to  seal  the  gums  to  the  teeth, 
prevent  infection  and  keep  out  all  food  particles.  This 
preparation  will  hold  from  24  to  48  hours,  is  an  astrin- 
gent, and  really  acts  as  a  splint,  drawing  the  gum  close 
to  the  teeth. 

While  there  are  some  men  who  seem  to  be  making  a 
success  of  implantation  work,  it  cannot  be  said  that  it  is 
as  great  a  success  in  pyorrhea  cases ;  greater  absorption 
of  the  alveolus  having  taken  place  together  with  the 
greater  danger  of  infection,  makes  the  chance  for  hold- 
ing less  than  in  a  healthy  mouth.  Still  this  is  a  great 
field  for  research  work  and  it  is  to  be  hoped  that  at  some 
future  time  methods  will  be  devised  for  overcoming  these 
difficulties. 

TREATMENT  OP  EXPOSED  BiFURCATIOlSr  IN"  MULTI-ROOTED  TEETH 

When  there  is  an  exposure  of  the  bifurcation  of  multi- 
rooted teeth,  especially  the  lower  molar  or  buccal  roots 
of  the  upper  teeth.  Smith  suggests  making  a  positive 
retention  cavity  between  the  roots  and  filling  this  with 
hard  gutta-percha,  forcing  it,  while  soft,  against  the  pro- 
cess and  gums  and  finishing  it  flush  with  the  tooth.    He 


Eemoval,  of  Pulps  iisr  Pyorrhea.  293 

says,  further,  that  this  simple  procedure  will  arrest  all 
recession  at  this  location. 

The  copper  cements  also  give  excellent  results  in 
good  locations  and  have  the  advantage  of  moulding  over 
the  gum  tissue  without  pressure  and  into  nooks  where 
it  is  difficult  to  place  gutta-percha. 

REMOVAL  OF  PULPS  IN  PYORRHEA  WORK. 

Whether  or  not  it  is  best  to  remove  pulps  in  operating 
for  pyorrhea,  is  a  subject  which  has  not  been  agreed 
upon.  There  are  operators  of  well  known  ability  who 
never  destroy  a  pulp  if  they  can  avoid  it.  Other  dentists, 
equally  capable,  destroy  pulps  in  pyorrhea  work.  These 
latter  men  claim  that  in  the  removal  of  the  pulp,  the 
nutriment  is  diverted  to  the  outer  surface  of  the  tooth, 
where  it  is  most  needed.  It  has  not  yet  been  explained 
by  these  operators,  the  modus  operandi  of  this  changing 
of  nutriment.  They  claim  that  a  devitalized  tooth  is 
never  attacked  by  pyorrhea,  but  it  has  been  borne  out  by 
observation  that  this  is  not  true,  nor  does  the  author 
deem  it  advisable  to  remove  the  pulp  of  the  tooth  for 
the  purpose  of  curing  pyorrhea,  for  if  there  is  ever  a 
time  when  a  tooth  needs  all  the  vital  force  and  nerve 
energy  which  it  originally  possessed,  it  is  at  the  time 
when  it  is  lame  from  pyorrhea;  whatever  results  have 
been  attained  fromi  the  removal  of  pulps,  were  in  those 
advanced  cases,  where  the  pulp  was  infected  by  the 
extension  of  the  disease  or  was  cut  off  by  tarter  deposit 
at  the  end  of  the  root.  Such  teeth  are  generally 
extracted,  but  the  teeth  which  we  leave  for  operative 
procedure  seldom  have  pockets  extending  to  the  end  of 
the  roots.  It  is  not  advisable  to  remove  these  pulps. 
However,  if  extra  sensitiveness,  due  to  infection,  is  a 
constant  symptom,  it  is  advisable  to  remove  the  pulp; 
remember  that  it  is  a  i^eculiar  coincidence  that  teeth 
affected  witli  porrhea  seem  to  have  the  most  crooked 
roots. 


294  Practical,  Pyorrhea  Alveolaris, 

*■  amputation  op  roots. 

If,  on  examination,  the  probe  can  be  pushed  entirely 
aronnd  the  root  of  any  multi-rooted  tooth,  and  over  the 
apex,  then  it  is  useless  to  attempt  to  save  this  root  as  it 
only  constitutes  a  foreign  body,  and  together  with  tlie 
surrounding  pocket,  forms  a  trap  for  future  infection  and 
food.  In  such  cases,  provided  the  other  root  or  roots 
have  good  attachment,  amputation  of  the  offending  root 
may  be  effected  and  the  remaining  portion  of  the  tooth 
made  to  do  service  for  years.  There  has  been  a  great 
deal  written  on  the  subject  of  amputation  of  roots  for 
alveolar  abscesses,  but  few  men  outside  of  specialists  in 
pyorrhea  seem  to  have  realized  the  great  value  of  this 
simple  surgical  procedure, 

I  have  performed  this  operation  successfully  in  sev- 
eral hundred  cases.  Many  of  these  teeth  so  operated  on 
over  eight  years  ago,  are  still  proving  successful  abut- 
ments for  bridges.  I  am  therefore  led  to  urge  upon  the 
general  practitioner  the  adoption  of  this  procedure  as  a 
routine  method  in  suitable  cases. 

Many  dentists  with  whom  I  have  talked,  have 
expressed  the  idea  that  it  is  extremely  difficult,  and  that 
they  were  afraid  to  undertake  it.  This  is  an  erroneous 
supposition;  the  field  for  operation  is  uncomplicated  by 
any  important  anatomical  structures  such  as  nerves  or 
arteries,  and  is  easily  accessible,  without  much  cutting 
or  the  necessity  for  an  anesthetic.  In  pyorrhea  work 
this  operation  is  confined  to  multi-rooted  teeth,  that  is, 
molars.  The  one  thing  to  be  decided  before  determining 
to  amputate  the  root  of  the  tooth  is  that  the  disease  and 
the  destruction  of  the  surrounding  bone  is  confined  to  this 
one  particular  root. 

The  most  frequent  places  where  amputation  is  needed 
are:  first,  the  palatal  root  of  the  molars;  second,  the 
posterior  buccal  root;  third,  the  anterior  buccal  root.  On 
the  lower  molar  teeth  we  most  frequently  amputate  the 


Amputatiozst  of  Eoots  iist  Pyoeehea.  295 

posterior  roots ;  tliese  are  tlie  most  difficult  roots  tliat  we 
have  to  remove. 

TECHNIQUE  OF  EOOT  AMPUTATION. 

This  operation,  to  be  satisfactory,  requires  that  the 
root  he  normally  separate  from  the  other  root,  or  roots, 
that  is,  they  must  not  be  fused  together  for  their  full 
length.  The  small  curved  probe  or  pyorrhea  instrument 
can  be  introduced  between  the  roots  to  determine  this. 
If  the  root  is  anastomosed  almost  to  the  top  with  its 
adjoining  root,  the  case  is  not  one  for  successful  opera- 
tion. This  caution  applies  particularly  to  the  buccal  root 
of  the  upper  molar,  as  it  is  very  seldom  that  a  complete 
union  of  the  palatal  root  or  the  lower  molar  root  takes 
place.  Before  beginning  the  operation,  it  is  advisable 
to  remove  the  pulp  of  the  tooth  and'  fill  the  pulp  canals 
in  the  best  way  possible,  for  after  one  of  the  roots  is 
taken  out,  it  is  very  difficult  to  find  the  canals.  However, 
the  writer  has  frequently  removed  roots  of  teeth  without 
paying  any  attention  whatever  to  the  tooth  pulps,  for 
the  shock  of  going  straight  through  so  paralized  the 
nerve  that  there  was  little  pain  to  the  operation.  The 
best  instrument  for  this  operation  is  a  long  shank  cross 
cut  fissue  bur.  This  is  to  be  used  in  a  right-angle  hand 
piece.  The  bur  is  introduced  in  the  bifurcation  and  with 
engine  revolving  rapidly  give  the  hand  piece  a  saw-like 
motion  towards  the  crown  of  the  tooth;  this  produces 
the  proper  slant  for  easy  removal  of  roots  and  self 
cleansing  space;  the  angle  at  which  we  point  the  hand 
piece  towards  the  crown  of  the  tooth  has  all  to  do  with 
the  easy  removal  of  the  separated  root.  As  a  general 
thing,  after  separation  of  the  root,  it  drops  back  into  the 
pocket  which  surrounds  it  and  can  be  easily  withdrawn 
with  a  pair  of  pliers.  As  the  tooth  upon  which  we  are 
operating  may  be  loose,  the  operator  always  braces  the 
tooth  securely,  either  with  his  hand  or  by  placing  a  small 
amount  of  warm  modelling  wax  against  several  of  the 


296  Practical  Pyorrhea  Alveolaris. 

teeth,  making  a  brace  so  as  not  to  have  any  undue  force 
on  the  part  of  the  tooth  which  we  wish  to  preserve. 

It  is  not  advisable  to  start  on  one  side  of  the  tooth 
and  later  remove  the  bur  and  begin  from  the  other  side 
of  the  root,  as  this  makes  a  ragged  operation.  How- 
ever, this  may  have  to  be  done  in  some  cases.  The  root 
having  been  removed,  the  next  step  is  to  polish  the  sur- 
face from  which  it  was  removed,  so  that  there  will  be  no 
sharp  or  jagged  edges  to  irritate  the  gums  or  catch  food. 
If  the  tooth  is  a  large  upper  first  or  second  molar,  it  is 
sometimes  advisable  to  remove  that  part  of  the  crown 
of  the  tooth  that  overhangs  the  place  where  the  root  came 
from,  as  too  much  leverage  would  tend  to  tip  the  tooth 
in  that  direction.  This  is  not  so  necessary  in  the  lower 
jaw,  as  here  the  crown  of  the  tooth  is  braced  by  the 
adjoining  tooth.  The  socket  from  which  the  root  was 
extracted  needs  very  little  attention  except  to  be  thor- 
oughly washed  out  with  warm  water  and  some  mild  anti- 
septice  solution  to  keep  it  free  from  food  until  it  fills 
up.  In  some  of  our  cases  it  is  hard  to  tell  that  an  ampu- 
tation has  been  done,  as  the  gum  soon  falls  into  place 
where  the  root  was  removed. 

As  this  operation  is  performed  in  such  a  manner  that 
the  parts  are  easy  to  keep  clean,  it  has  not  often  been 
found  that  any  decay  set  in  from  exposure  of  dentine. 
Sometimes  it  is  very  important  to  make  correction  of 
malocclusion  in  these  teeth  in  order  to  prevent  any  undue 
force  being  put  upon  a  tooth  which  is  naturally  weaker 
than  normal.  In  fact,  it  is  a  good  idea  to  lower  the 
occlusion  on  a  tooth  from  which  a  root  has  been  taken. 

AMPUTATION  OF  ROOTS  FOR  BRIDGE  WORK. 

The  prettiest  result  of  root  amputation  is  where  the 
remaining  part  of  the  tooth  is  to  be  used  as  a  bridge 
abutment.  Every  abutment  which  can  be  used  in  bridge 
work  adds  to  its  strengtli  and  should  be  saved,  especially 
in  pyorrhea  mouths  where  all  the  rest  of  the  abutments 


Treatment  of  Pyoerheal.  Alveolar  Abscess.     297 

may  be  in  a  shaky  condition.  We  have  all  observed  in  a 
boat  landing  where  piles  were  being  driven,  that  one  or 
two  of  them  seemed  loose,  but  when  lashed  together  an 
ocean  steamship  could  hardly  shake  them.  In  the  same 
way  it  is  desirable  to  give  every  possible  support  for 
bridge  work,  even  though  some  of  them,  alone,  may  seem 
very  weak. 

In  using  these  teeth  for  bridge  abutments  it  is  desir- 
able that  the  whole  of  the  crown  be  removed  and  small 
platinum  coping  be  placed  just  under  the  gun  margin,  I 
have  always  found  this  to  be  easier  and  of  better  success. 

TREATMENT  OF  PYOERHEAL  ALVEOLAR  ABSCESS. 

If  the  operator  is  familiar  with  the  formation  of  a 
pyorrheal  abscess  (described  elsewhere)  the  treatment  is 
a  simple  matter. 

The  patients  come  in  very  much  alarmed  at  the  sudden 
condition  of  one  of  their  teeth.  This  alarm  can  be  quickly 
turned  to  quiet  and  confidence  if  the  proper  treatment 
is  given. 

Do  not  attempt  to  lance  the  swollen  area  but  with  a 
Younger  instrument.  Number  1  or  2,  carefully  insert  at 
cervical  edge  between  gum  and  tooth  toward  the  swelling. 
This  should  not  hurt  the  patient;  almost  the  weight  of 
the  instrument  will  be  sufficient  to  enter  the  pocket  and 
allow  the  pus  which  is  under  pressure  to  escape.  Now, 
at  this  stage,  do  not  attempt  to  do  any  root  scraping  or 
planing,  but  with  a  small  pointed  syringe  insert  at  the 
point  where  the  instrument  was  passed  and  using  gentle 
pressure  wash  out  the  cavity.  Repeat  this  several  times. 
Do  not  use  any  strong  irritating  liquids,  but  use  either 
hot  normal  salt  solution  or  water  with  phenol,  five  drops 
to  six  ounces.  -  This  operation  should  be  repeated  the 
following  day. 

At  some  subsequent  date  when  the  tissues  are  less 
painful,  the  tooth  should  be  treated  for  the  pyorrheal 
condition. 


CHAPTEE     XXXIII. 

VACCINATIOlSr    TREATMENT. BEIDGE    WORK    AND 

SPLINTS  FOE  PYORRHEA. THE  X-RAY  AND  PYORRHEA,  MACKEE. 

AUTOGENOUS   VACCINATION   FOR   THE    TREATMENT    OF 
PYORRHEA. 

Autogenous  vaccination  for  the  treatment  of  pyorrhea. 
The  author  has  been  so  successful  in  treating  pyorrhea 
according  to  methods  described  elsewhere,  that  the  sub- 
ject of  vaccines  has  not  had  much  attention  in  his  prac- 
tice. In  discussing  this  subject  at  the  last  National 
Dental  Association  in  Washington,  Dr.  Rhein  made  the 
statement  that  when  vaccination  became  necessary,  the 
ordinary  dentist  was  not  a  necessity  because  the  patient 
was  a  fit  subject  for  the  hospital. 

Several  years  as  oral  surgeon  on  the  staff  of  the  City 
Hospital  of  Atlanta,  gave  me  an  opportunity  to  see 
extreme  cases  of  oral  sepsis.  At  that  time  only  stock 
vaccines  were  to  be  had,  and  we  used  only  the  vaccine  of 
the  predominating  infection.  I  never  could  see  any 
special  improvement  and  several  of  the  patients  died. 

In  order  that  the  reader  of  this  book  may  become 
familiar  with  the  elementary  facts  on  which  this  treat- 
ment is  based,  I  give  the  following  article  by  Dr.  George 
B.  Harris,  which  was  published  in  the  Dental  Summary. 

"The  use  of  vaccines  in  the  treatment  of  pyorrhea  is  not  to  take 
the  place  of  the  local  treatment  of  instruanentation  in  any  way.  How- 
ever, it  becomes  a  very  valuable  agent  when  used  to  overcome  the 
infection  present  and  in  maintaining  a  condition  that  makes  the  growth 
of  bacteria  impossible  over  a  period  of  sufficient  length  to  permit  re- 
generation. It  not  only  does  this,  but  it  also  prevents  the  recurrences  of 
pyorrhea  after  a  cure  has  been  effected  by  fortyfying  the  individual 
against  the  bacteria.  Protection  against  recurrence  is  'as  important  as 
a  cure  itself.  Stock  vaccines  may  be  used  to  do  this,  but  it  has  been 
my  experience  that  the  Autogenous  Vaccines  give  from  50  to  75  per 
coit.  better  results. 

"The  first  step  in  making  a  vaccine  of  this  kind  is  the  obtaining 


Autogenous  Vaocination.  299 

of  the  pus.  This  should  be  obtained  in  as  pure  a  culture  as  possible. 
Carefully  remove  all  tartar  deposits  from  the  teeth j  paint  the  tooth 
and  gum  with  iodin  and  dry.  On  the  following  day  remove  all  food 
particles,  dry  with  alcohol  again,  paint  the  gum  with  iodin,  and  diy. 
Then  carefully  force  out  a  small  amount  of  pus  from  under  the  gum, 
collect  on  a  sterile  platinum  wire  and  inoculate  an  agar  tube.  Allow 
this  to  genninate  from  twenty-four  to  forty-eight  hours.  If  a  pure 
culture  has  been  obtained,  which  is  generally  the  case  if  the  preceding 
operations  have  been  carefully  done  the  vaccine  may  be  made  directly 
from  the  first  culture  and  several  days  saved;  otherwise  new  cultures 
must  be  made  from  the  predominating  culture  in  the  initial  tube. 

"Remove  as  many  of  the  cultures  as  possible,  care  being  taken  not  to 
take  up  any  agar  with  the  cultures.  These  are  now  transfei-red  to  a 
tube  containing  distilled  sterile  water.  This  is  shaken  vigorously  to 
break  up  all  clusters.  A  centrifugal  machine  should  be  used  for  this 
purpose,  but  if  one  is  not  to  be  had  it  can  satisfactorily  be  done  by 
hand.  One-half  a  cubic  centimeter  is  now  drawn  up  and  transferii^ed 
to  another  test  tube.  This  is  used  in  the  determination  of  the  number 
of  bacteria  we  may  have  in  the  concentrated  solution  and  is  not  made 
into  vaccine.  To  this  is  added  two  cu.  em.  of  water  to  make  the  counting 
easier  and  more  accurate.  About  half  a  cu.  em.  of  this  diluted  solution 
is  now  drawn  up  in  an  opsonizing  pipette  and  an  equal  amount  of 
normal  blood  taken  directly  after.  This  is  blown  out  on  a  slide  and 
mixed.  A  drop  is  then  placed  on  a  cover  glass,  dried,  mounted  and 
stained.  Place  the  slide  on  the  counting  chamber  and  count  the  cor- 
puscles and  germs  in  the  successive  fields  until  at  least  250  corpuscles 
are  counted.  Since  there  are  5,000,000  corpuscles  in  a  cu.  mm.  of 
blood,  by  a  simple  proportional  equation  we  can  determine  the  number 
of  bacteria  in  the  dilute  solution.  By  multiplying  the  number  of 
germs  in  the  dilute  solution  by  the  number  of  times  it  was  diluted, 
we  determine  the  number  of  germs  in  the  concentrated  solution  per  cu. 
mm..  Since  there  are  1,000  cu.  mm.  in  a  cu.  em.,  by  multiplying  the 
number  per  cu.  mm.  by  1,000  we  determine  the  number  per  cu.  ce.  For 
example:  Suppose  we  counted  250  corpuscles  and  50  bacteria.  Since 
we  know  that  there  are  5,000,000  corpuscles  on  one  cubic  millimeter  of 
blood,  the  following  proportion  is  established :  250  :5.000,000  :  :50  :X. 

"Solving  this  proportion,  we  find  there  are  1.000,000  bacteria  per 
cu.  mm.  Since  there  are  1,000  cu.  mm.  in  a  cu.  ec.  we  find  1,000,- 
000,000  bacteria  to  each  cu.  ce.  in  the  dilute  solution.  Since  we  diluted 
the  solution  four  times,  there  are  4,000,000,000  bacteria  to  each  cu.  ce. 
in  the  concentrated  solution.  The  vaccine  is  now  ready  to  be  stand- 
ardized. It  is  first  diluted  to  the  strengih  we  wish  to  have  it;  heated 
at  60  degTees  for  an  hour,  then  4  per  cent,  tricresol  added  to  prevent 
contamination,  and  sealed. 


300 


Peactical  Pyokehea  Alveolaeis. 


Any  loose  tissue  may  be  selected  as  the  site    of  injection.     The  most 
importaut  things  to  look  out  for  are: 
''1.  Be  sure  the  solution  is  sterile. 

"2.  Absolute  cleanliness  of  the  skin  at  the  site  of  injection. 
"3.  Use  gTeat  care  in  avoiding  veins. 
"4.  Be  sure  the  count  is  accurate." 

BEIDGE  WOEK   IN  PYOEEHEA. 

In  treating  a  case  of  pyorrhea,  bridge  work  is  often 
necessary.  The  character  of  this  work  has  a  great  deal 
to  do  with  the  permanency  of  onr  resnlts ;  many  special- 
ists prefer  to  do  this  mechanical  work  themselves  accord- 
ing to  their  own  ideas,  and  in  fact,  one  or  two  specialists 
will  not  accept  a  case  referred  to  them  by  other  dentists 
unless  this  provision  is  made.  The  reason  for  this  is  that 
considerable  deviation  from  the  regular  established  sys- 
tem of  bridge  work  is  often  indicated,  in  that  we  have 
to  use  more  teeth  for  support  than  we  would  in  a  normal 
mouth. 


Fii;.  \i.     STvrj''.  of  Ukidck  Work  Most  UsKinrii  tn  l^'Ol;l;ll^;A  Mouths 

(TirTKRr'ir). 


Tn  the  construction  of  this  work  all  sides  of  the  abut- 
ment teeth  should  be  accessible  for  instrumentation,  and 
the  central  idea  for  bridge  work  of  this  kind  is  that  it 


Splixts  in  Pyoeehea  Alveolaeis.  301 

must  l)e  so  constructed  as  to  be  easily  cleaned  by  the 
patient.  Tliis  fact  is  sometimes  lost  sight  of  by  the 
mechanical  man  whose  sole  idea  is  to  restore  the  lost 
teeth  and  to  fill  the  space  completely. 


Fig.  48.     Lixgual  Surface,  Upper  Jaw,  Bridge  Work  in 
ProRRHEA  Cases. 

After  finishing  onr  treatment,  if  we  find  several  teeth 
still  loose  and  several  to  be  replaced,  we  can  not  only 
replace  the  lost  teeth,  but  can  bind  the  loose  ones 
together  furnishing  the  best  kind  of  splint.  Thus  the 
pressure  is  distributed  over  a  larger  area  so  that  it  is 
not  too  great  on  any  one  tooth.  For  any  extensions  on 
the  bridge,  it  is  well  to  make  saddles  to  extend  on  either 
side  of  the  alveolar  ridge  so  as  to  give  the  extension  sup- 
port from  lateral  strains.  All  soldering  of  abutments 
should  be  as  near  the  occlusal  surfaces  as  possible,  so 
that  we  may  have  better  access  to  the  root  surfaces  in 
case  a  pocket  develops  there  at  any  time.  Smaller 
amounts  of  solder  can  be  used  if  platinum  wire  is 
soldered  or  waxed  in  and  cast  into  the  abutments  at  the 
places  of  joining. 

SPLINTS. 

Many  varied  and  ingenious  devices  for  the  retention 
of  loose  teeth  in  pyorrhea  have  been  described  in  dental 


302  Practical.  Pyorrhea  Alveolaris. 

journals  and  demonstrated  in  clinics;  the  author  dis- 
cusses, in  the  following  pages,  the  use  and  making  of 
splints. 

The  very  fact  that  teeth  have  to  be  splinted  in  order 
that  they  may  be  saved,  makes  them  a  source  of  frequent 
infection,  and  they  will  need  frequent  attention  from  the 
dentist  to  keep  them  in  proper  shape. 

Splints  are  of  two  kinds,  temporary  and  permanent. 
The  temporary  splint  is  of  greatest  advantage.  It  is 
sometimes  well  to  use  some  form  of  temporary  splint  at 
the  time  of  operation  so  as  not  to  give  the  teeth  too  much 
strain  during  the  operation.  If  this  is  not  done,  it  is 
well  to  do  so  after  the  operation^  so  as  to  give  the  teeth 
a  rest  and  chance  to  regain  some  strength.  This  applies 
particularly  to  the  lower  anterior  teeth  and  the  superior 
laterals. 

Perhaps  waxed  floss  silk,  laced  in  between  the  teeth 
in  figure  8  fashion,  forms  the  best  temporary  splint; 
this  can  be  removed  every  day  or  two.  To  prevent  the 
splint  from  slipping  down  into  the  gums  a  little  cement 
can  be  placed  upon  the  surface  of  the  teeth.  Orthodontia 
wire  is  also  excellent  for  this  purpose.  Di*.  J.  W. 
Jungman  suggests  the  following :  '  'Eoll  out  the  ordinary 
Angle  orthodontia  wire  to  a  ribbon;  anneal  and  gold 
plate.  Start  from  left  to  right  by  forcing  the  wire  down 
between  the  bicuspid  and  cuspid;  then  lace  it,  carrying 
the  strands  over  and  under  so  as  to  lock  them.  At  the 
right  cuspid,  wind  one  strand  around  the  other,  and  force 
it  between  the  cuspid  and  bicuspid  so  as  not  to  irritate 
the  lip.  Where  there  are  one  or  two  loose  teeth,  I  usually 
carry  to  the  adjoining  teeth  only." 

dr.  w.  f.  spies'  temporary  splint. 

"There  are  many  ways  in  which  a  temporary  splint 
can  be  made,  either  by  the  use  of  silk  or  wire.  Illustra- 
tion shows  a  form  of  temporary  wire  splint  which  need 
not  be  changed,  is  clean,  and  if  properly  applied  does 


Splints  in  Pyoerhea  Alveolaeis.  303 

not  draw  the  teetli  together  as  does  the  silk.  It  is  made 
by  using  26  gauge  gold  ligature  wire  for  the  slip-noose 
and  30  gauge  for  the  wires  between  the  teeth.  Make  a 
slip-noose  over  the  teeth  to  be  enelosd,  by  bringing  one 
end  of  the  wire  over  the  other,  but  not  twisting  them 
together.  Cut  short  pieces  of  wire  to  be  used  between 
each  two  teeth,  twist  the  ends  together,  and  draw  tight. 
These  wires  should  be  cut  to  such  length  that  the  ends  may 
be  turned  back  into  the  interproximal  space  without 
touching  the  gum  tissues.  The  ends  of  the  wire  of  the 
first  slip-noose  should  now  be  twisted  together." 


Fig.  49.    Temporary  Wire  Splint  (Spies). 

Dr.  Robert  Good's  method  of  ligating  teeth  is  to  use 
A,  B  or  C  sewing  silk,  having  it  well  waxed.  Select  tooth 
for  anchorage,  then  pass  ligature  twice  around  this  tooth 
(making  double  loop)  and  fasten  by  making  double  knot 
and  single  knot  on  top  double  one.  Now  make  single 
loop  around  next  tooth  and  make  knots  the  same  as  before 
and  continue  in  this  manner,  until  you  have  included  the 
number  of  teeth  you  wish  to  ligate  or  make  fast.  When 
the  last  tooth  to  be  included  is  reached,  make  double  loop 
again  and  return  making  the  loops  the  same  as  before, 
this  will  give  two  rows  of  ligatures,  making  the  teeth 
quite  rigid.  Three  rows  or  more  may  be  used,  making 
a  splint  that  will  remain  for  six  or  eight  weeks.  Care 
should  be  taken  to  place  the  ligatures  on  the  teeth  in  a 
position  where  they  will  slip  neither  up  or  down,  but 
remain  where  placed. 


304  Practical,  Pyorrhea  Alveolaris. 

lu  iisiug  these  temporary  splints,  it  is  well  to  be  cer- 
tain that  no  undue  strain  is  placed  on  the  teeth,  pulling 
them  out  of  position.  Where  space  exists,  nmnj  knots 
may  be  tied  to  bridge  this,  or  the  wire  twisted  between 
the  teeth,  so  as  not  to  draw  them  into  the  space. 

The  writer  has  seen  cases  where  the  wire  was  placed 
for  temporary  splints  to  be  removed  at  a  stated  time, 
but  for  some  cause  the  patient  got  away  without  its  being 
removed,  and  it  remained  several  years  without  discom- 
fort. "Wire  has  the  advantage  of  being  easily  put  on 
and  easily  replaced ;  it  shows  no  metal  and  is  easy  to  keep 
clean.  If  it  is  desired  to  be  permanent,  little  nicks  can 
be  cut  with  a  fissure  bur  run  between  the  teeth;  this 
will  hold  the  wire  secure  and  prevent  it  from  slipping 
into  the  gums.  Sometimes  a  little  cement  to  hold  it  in 
place  will  last  for  years.  The  advent  of  cast  work  has 
opened  a  new  field  for  the  ingenuity  of  the  operator  in 
the  line  of  dental  splints ;  small  inlays  can  be  made  which 
are  easily  inserted  and  this  will  probably  be  the  means 
adopted  for  splints  in  the  future.  The  old  method  of 
swaging  these  splints  and  soldering  them  up  did  not  pro- 
duce the  results  which  we  hoped  it  would. 

In  devising  the  splint,  the  main  requisite  is  to  hold  the 
tooth  rigidly  in  its  proper  position.  It  must  be  self- 
cleansing  or  easily  cleaned  by  the  patient.  Again,  it 
must  not  extend  to  the  gum  margin  to  fill  up  the  inter- 
stitial space,  but  must  be  left  so  that  instrumentation  of 
the  root  surface  can  be  done  with  ease. 

However,  after  all  is  said  and  done,  it  seems  to  me 
as  though  it  is  not  of  the  most  benefit  to  retain  the  teeth 
which  have  to  be  placed  in  splints,  and  it  does  seem  to 
be  the  best  policy  in  the  beginning  to  extract  those  teeth 
which  the  operator  will  soon  learn  by  experience  will 
never  be  kept  in  a  healthy  condition,  and  which  may 
require  extraction  later  on. 


Badiograpiis    Illustrating   "The   X-Eay   and   Pyori;iiea.  ' '— MacKee. 


X-Eay  iisr  Pyorrhea,  305 

THE   X-RAY  AND   PYORRHEA. 
BY  GEORGE   M.   MACKEE,   M.  D.,   NEW   YORK. 

'^  Wliile  tlie  value  of  the  X-ray  in  pyorrhea  alveolaris  is 
exceedingly  limited,  yet  there  are  factors  of  interest  and 
of  importance  that  should  be  enumerated  and  to  some 
extent  elaborated. 

' '  In  the  first  place  it  is  extremely  doubtful  if  the  X-ray 
possesses  any  therapeutic  value  in  Rigg's  disease,  either 
in  the  early  or  late  stages.  It  might  be  explained  that 
there  is  evidence  in  supi^ort  of  the  contention  that"  when 
the  X-ray  is  applied  to  certain  superficial  bacterial  affec- 
tions a  local  autogenous  vaccine  is  produced.  A¥e  have 
here  a  possible  ex23lanation  of  the  rapid  involution  of 
some  types  of  acne  and  sycosis  when  exposed  to  the 
X-ray.  It  should  be  stated,  in  this  connection,  that  the 
X-ray  has  no  direct  effect  upon  bacteria.  Pyorrhea,  how- 
ever, affects  tissues  that  are  more  deeply  seated  than  are 
the  diseases  just  mentioned  and  these  tissues  are  so  lo- 
cated that  the  ray  loses  much  of  its  therapeutic  value 
before  reaching  them.  Theoretically,  perhaps,  certain 
types  and  stages  of  pyorrhea  should  be  benefited  by 
radio-therapeutic  measures,  but  from  a  practical  stand- 
point, there  are  no  authentic  or  verified  reports  of 
pyorrhea  being  controlled  by  radio-thera]3eutic  measures. 
And  it  should  be  remarked  in  passing,  that  small  doses 
of  the  X-ray  applied  over  a  long  period  of  time  may  cause 
atrophy  of  the  glandular  and  interstitial  tissues,  sclerosis 
of  the  deeper  hmipliatic  and  blood  vessels,  dilatation  of 
the  superficial  capillaries  and,  finally,  precancerous  and 
even  malignant  degeneration.  And,  furthermore,  these 
changes  may  not  become  manifest  for  months  or  even 
years  after  cessation  of  treatment. 

''Whatever  value  the  X-ray  possesses  in  relation  to 
pyorrhea  is  in  a  diagnostic  capacity.  A  radiographic  ex- 
amination will  determine  if  the  alveolus  has  or  has  not 


306  Pkactical  Pyokkhea  Alveolaris. 

become  involved  in  tlie  process — providing,  of  course, 
that  the  bone  has  become  sufficiently  diseased  to  be  radio- 
graphically  depicted.  Naturally  the  extent  of  the  bony 
involvement  may  be  detected.  The  presence  of  suspected 
or  unsuspected  complications  may  be  also  elicited — as, 
for  instance,  supernumerary,  unerupted  and  impacted 
teeth,  apical  abscesses,  disease  of  the  maxillary  sinuses, 
exostosis,  cystic  degeneration,  etc. 

'^Typical  pyorrhea,  when  well  advanced,  presents  a 
rather  characteristic  radiographic  appearance  (Fig.  A, 
published  in  Items  of  Interest,  June,  1913,  Dr.  A.  H. 
Merritt's  patient).  Here  there  is  a  light  shadow  (dark 
shadow  on  the  original  radiograph)  extending  from  the 
margin  of  the  alveolus  around  the  roots  and  apices  of 
the  teeth,  and  indicating  that  the  greatest  destruction  of 
bone  has  been  around  the  necks  of  the  teeth.  Although 
this  appearance  is  typical  of  pyorrhea,  yet  other  condi- 
tions may  possibly  produce  a  similar  picture — for  in- 
stance, mercurial  stomatitis,  rachitis,  etc. 

' '  Further,  the  light  shadow  already  mentioned,  simply 
indicates  lessened  resistance  to  the  X-ray.  That  is  to 
say,  that  the  ray  has  penetrated  this  particular  portion 
of  the  alveolus  with  greater  facility  than  in  neighboring 
regions.  A  shadow  of  this  kind,  then,  indicates  a  loss 
of  mineral  substance  and  may  signify  atrophy,  regenera- 
tion or  actual  necrosis  of  bone.  In  some  instances  it  is 
possible  for  the  radiologist,  from  a  study  of  the  density 
of  the  shadows,  the  presence  or  absence  of  bone  detail, 
etc.,  to  determine  if  he  is  dealing  with  any  one  or  all  of 
these  factors — in  many  cases,  however,  this  is  quite 
impossible. 

''In  differentiation,  if  necrosis  or  disease  begins  at  the 
apex  of  a  tooth  and  is  due  to  infection  from  the  tooth, 
the  area  of  disturbance  is  likely  to  be  circumscribed 
(Fig.  2,  Dr.  M.  L.  Collin's  patient,  published  in  Items  of 
Interest,  June,  1913).  On  the  other  hand  there  are  in- 
stances where  both   conditions   are   seemingly  present 


Eadiographs   Illustkatixg   "The   X-Eay   and    Pyorrhea.  "—:\rAcKEE. 


X-Ray  in  Pyokrhea.  307 

(Fig.  3,  Dr.  H.  S.  Dunning 's  patient).  Here  there  is  a 
marked  absorption  of  bone  around  the  apex  of  the  cuspid. 
The  location  and  appearance  of  the  shadow  would  lead 
one  to  suspect  necrosis  as  a  result  of  an  apical  abscess. 
There  is,  also  a  marked  absorption  of  bone  around  the 
neck  of  the  tooth,  which  resembles  pyorrhea  to  a  marked 
degree.  It  will  be  noticed  that  the  filling  extends  not 
quite  to  the  apex ;  above  this  point  the  pulp  canal  appears 
to  be  obliterated.    The  apex  itself  is  slightly  eroded. 

"In  Fig.  4,  is  shown  an  area  of  absorption  apparently 
in  relation  to,  and  possibly  originating  from,  infection 
through  the  posterior  root  of  the  molar.  This  shadow 
connects  with  the  thinned  bone  left  by  a  previous  extrac- 
tion. The  general  appearance  is  somewhat  that  of 
pyorrhea.    (Patient  referred  by  Dr.  H.  S.  Dunning.) 

"Fig.  5  depicts  loss  of  bone  in  the  molar  region  over 
a  dummy  tooth.  This,  too,  has  the  appearance  of 
pyorrhea,  but  is  possibly  due  to  pressure  or  local  irrita- 
tion.    (Patient  referred  by  Dr.  W.  A.  Hillis.) 

"Fig.  6  shows  absorption  around  the  apex,  root  and 
neck  of  the  tooth.  The  radiographic  appearance  is  that 
of  pyorrhea,  but  might  it  not  be  the  result  of  an  apical 
abscess  with  a  sinus  running  along  the  root  of  the  tooth? 
(patient  referred  by  Dr.  T.  P.  Hyatt). 

"Fig.  7  (Dr.  T.  P.  Hyatt's  patient,  published  in  Items 
of  Interest,  June,  1913),  shows  a  large  cavity  in  the 
mandible,  apparently  involving  several  teeth  and  due  to 
an  infected  cyst. 

"The  remaining  illustrations  are  presented  in  order 
to  demonstrate  complications  that  are  not  infrequently 
found  associated  with  pyorrhea.  They  were  all  published 
in  the  Items  of  Interest  for  June,  1913 :  Fig.  8 — exosto- 
sis; Dr.  N.  B.  Potter's  case.  Fig.  9 — old  bicuspid  root 
in  situ.    Fig.  10 — possible  pulp  stones  in  molars. 

"A  study  of  these  few  radiographs  may  convince  one 
of  the  value  of  radiography  in  pyorrhea.     It   should 


308  Practical  Pyoeehea  Alveolaeis. 

demonstrate,  also,  the  fact  that  the  radiologist  alone,  at 
least  in  many  cases,  is  nnable  to  make  a  diagnosis.  In- 
deed, it  is  not  his  dnt}^  to  make  the  diagnosis.  He  should 
first  make  a  careful  and  complete  radiographic  examina- 
tion and  then  interpret  the  radiographs  from  a  radio- 
graphic standpoint.  He  should  separate  radiographi- 
cally  anatomical  from  radiographically  pathological  con- 
ditions and  he  should  call  attention  to  photographic, 
radiographic  and  other  forms  of  technical  arti-facts.  In 
other  words  it  is  within  his  province  to  give  a  detailed 
radiographic  and  other  forms  of  technical  artifacts.  In 
perience,  skill  and  a  thorough  radiographic  examination 
of  the  patient,  together  with  ^  careful  study  of  the  re- 
sulting radiographs.  This,  together  with  the  clinical 
findings,  will,  as  a  rule,  enable  the  dental  surgeon  to  con- 
struct or  deduce  a  diagnosis." 


CHxlPTEE     XXXIV. 

STEEILIZATIOX    OF    IXSTEUMEXTS    AXD    PEEPAEATIOX    OF    THE 
MOrTH  FOR  SUEGICAL  WOEK. 

If  there  is  one  thing  about  which  the  medical  man 
has  cause  to  laugh  at  the  dentist,  it  is  regarding  the 
dentist's  neglect  of  sterilizing  instruments  and  clean- 
ing the  field  of  operation.  The  colleges  are  largely  to 
blame  because  they  do  not  lay  sufficient  stress  on  these 
subjects  and  do  not  require  the  dental  students  to  prac- 
tice the  proper  methods  of  sterilization  in  their  college 
course. 

The  farcical  nature  of  our  processes  probably  does 
not  depend  so  much  on  a  lack  of  interest  or  desire  to  do 
the  proper  thing,  as  the  lack  of  knowledge  along  these 
lines.  In  ordinary  dental  work,  such  as  bridge  work, 
crowns,  and  plates,  it  may  not  be  of  so  much  importance ; 
but  when  it  comes  to  such  work  as  prophylaxis  and 
pyorrhea,  it  is  fully  as  important  as  in  any  other  surgical 
work. 

Not  long  ago  it  was  noted  that  a  professor  of  oral 
surgery  in  one  of  our  colleges,  in  consultation,  asked  his 
assistant  for  a  nerve  broach,  which  was  handed  to  liim 
from  the  regular  cabinet  stock.  He  dipped  it  into 
alcohol  for  one  second  and  then  proceeded  to  use  it,  evi- 
dently under  the  impression  that  he  was  using  a  per- 
fectly sterilized  instrument.  When  a  teacher  makes  such 
errors  as  this,  is  it  to  be  wondered  at.  that  young  dentists 
make  mistakes? 

The  simple  dipping  of  instruments  into  alcohol  is  not 
effective;  the  sterilizers  that  are  generally  furnished  the 
dentists  are  also  inefficient.  They  put  up  a  good  appear- 
ance, but  further  than  this  they  are  not  worth  much. 
Methods  of  sterilization  are  of  two  kinds,  antiseptic  and 
heat.     Alcohol  in  a  jar  shaped  like  a  fruit  jar  with  a 


310  Peactical  Oeal.  Hygiene. 

screw  top  furnishes  a  convenient  and  effective  recep- 
tacle. The  instruments,  both  before  and  after  the  opera- 
tion, must  be  thoroughly  cleaned  in  running  water  with 
a  clean  brush,  and  then  placed  in  the  jar  just  mentioned 
and  allowed  to  remain  there  for  at  least  five  minutes, 
when  they  can  be  taken  out,  and  dried,  or  the  alcohol 
burned  off  by  bringing  them  in  contact  with  a  small 
flame. 

Lysol  and  bichloride  solutions  are  not  to  be  recom- 
mended for  this  particular  line  of  work,  because  if  used 
strong  enough  to  be  effective,  the  mucous  membrane  of 
the  mouth  would  be  injured.  Undoubtedly,  the  best  form 
of  sterilization  yet  found  is  heat.  By  heat,  I  do  not  mean 
the  simple  dipping  of  the  instruments  into  hot  water, 
but  the  whole  instrument  must  be  boiled  for  at  least  five 
minutes.  In  the  summer  time,  to  have  a  boiling  recep- 
tacle in  our  offices,  is  not  the  most  pleasant  companion. 
However,  it  will  be  found  to  be  the  best  sterilizer  i  it  also 
gives  a  good  impression  and  is  one  of  the  best  advertise- 
ments a  dentist  can  have  outside  of  good  work.  Undoubt- 
edly, dental  manufacturers  realize  this  because  all  steril- 
izers have  the  word  ''sterilizer"  written  in  large  letters 
across  the  front  of  the  apparatus. 

Not  only  the  dentist's  instruments  and  material 
should  be  sterilized,  but  the  dentist's  hands  should 
be  rendered  as  nearly  aseptic  as  possible.  After  they 
have  been  thoroughly  washed  with  a  good  grade  of 
soap  and  a  nail  brush,  a  few  drops  of  alcohol  should  be 
rubbed  into  them;  this  not  only  destroys  the  bacteria 
which  may  have  been  received  from  the  previous  patient, 
but  makes  the  approach  to  the  next  patient  more  agree- 
able. The  best  way  to  manage  this  is  by  means  of  a  shelf 
suspended  above  the  wash  bowl,  on  which  is  placed  a 
fountain  bottle  as  ])er  illustration  (No.  51).  This  is 
filled  with  grain  alcohol,  to  wliicli  may  be  added  some 
good  toilet  water. 


Cleansing  the  Field  op  Operation. 


311 


CLEANSING  THE  FIELD  OF  OPERATION. 

Peroxide  of  Hydrogen  is  a  good  agent  to  be  used  in 
mopping  out  the  mouth.  It  can  be  applied  by  use  of  a 
cotton  swab  held  by  Skinner's  ''Kuoris."  If  it  is  not 
desirable  to  use  peroxide,  which  is  unpleasant  to  say  the 
least  of  it,  we  can  substitute  a  solution  of  aromatic  spirits 
of  ammonia,  one  part  in  five  parts  of  water.  This  used 
as  a  spray  or  on  a  mop  is  very  efficient  for  cutting  loose 


Fig.   51. 


the  thick  mucus  covering  the  inside  of  the  mouth,  and 
at  the  same  time,  it  is  very  cooling  and  pleasant  for  the 
patient.  Next  the  gum  surfaces  and  the  infected  area 
may  be  coated  with  either  Buckley's  Pyorrhea  Astrin- 
gent, but  preferably  with  Skinner's  Disclosing  Solution, 
previously  described.  The  ordinaiy  tincture  of  iodine  is 
not  so  pleasant  nor  does  it  remain  on  so  long  as  the 
Skinner's  Disclosing  Solution.  If  the  mouth  has  been 
thoroughly  mopped  out,  the  antiseptic  solution  applied 
over  all  the  surfaces,  and  the  debris  removed  from  open 
cavities  which  are  filled,  temporarily,  with  sandarac 
varnish  and  cotton,  or  with  gutta-percha,  we  have  done 
about  all  that  is  possible  towards  rendering  the  field  of 
operation  sterile. 


CHAPTEE     XXXV. 

BUSINESS    SIDE   OF  PYOERHEA  ALVEOLAEIS. 

Dental  offices  have  been  flooded  with  all  kinds  of  liter- 
ature calling  attention  to  certain  medicines  and  prepara- 
tions which  would  "positively  cure  pyorrhea."  Many 
of  these  preparations  were  accompanied  by  extracts 
from  papers  by  some  of  the  most  prominent  men  in  our 
profession,  who  claimed  that  pyorrhea  was  of  constitu- 
tional origin,  and  that  such  and  such  a  remedy  was  the 
only  thing  to  use.  Others  gave  their  endorsement  to  the 
various  local  remedies  which  needed  but  to  be  applied 
several  times  for  a  complete  cure.  These  preparations, 
having  come  so  highly  recommended  by  the  profession, 
were  tried  out  by  the  dentists,  but  the  cases  of  pyorrhea 
on  which  they  were  used  were  not  cured.  The  failure  of 
all  these  remedies  has  made  the  general  practitioner  very 
skeptical  as  to  the  possibilities  of  curing  pyorrhea,  and 
it  is  undoubtedly  one  reason  why  so  few  practitioners 
have  undertaken  to  treat  this  disease.  The  business  of 
treating  pyorrhea  was  hirgely  the  sale  of  proprietary 
drug  preparations. 

Anotlier  reason  for  lack  of  interest  in  pyorrhea  treat- 
ment was  the  fact  that  the  dentist  did  not  try,  or  was 
not  able  to  secure  from  the  patient  the  ])ro])er  remunera- 
tion for  the  work.  I  have  been  unable  to  understand  just 
why  this  is  so,  unless  it  is  the  failure  on  the  part  of  the 
patient  to  realize  the  gravity  of  a  beginning  pyorrhea. 
The  patient  thinks  that  only  his  teeth  need  cleaning  and 
that  it  is  worth  probably  $1.00  to  do  tliis. 

Within  the  last  few  years,  a  number  of  good  men  have 
specialized  on  (Mther  prophylaxis  or  pyorrhea  work  and 
the  good  work  that  has  be(m  done  has  forced  on  the  pro- 
fession the  recognition  of  the  fact  that  pyorrhea  work 
re({uires  tlie  greatest  degree  of  skill  and  is  probably  the 
greatest  service  that  we  can  render  our  patients.     This 


Business  Side  of  Pyoerhea  Alveolaeis.  313 

work  should  command  the  largest  fees  that  a  dentist  is 
able  to  command.  It  is  a  fact  that  patients  of  means  and 
refinement  are  most  appreciative  and  willing  to  pay  large 
fees  to  the  men  who  can  save  their  teeth  from  pyorrhea. 

One  way  is  to  charge  for  time,  as  in  other  dental 
work;  this  plan  has  serious  drawbacks,  and  it  seems  to 
me  that  it  is  not  the  proper  idea  for  surgical  work.  From 
the  letter  of  a  prominent  California  dentist,  who  does 
considerable  work  along  this  line,  I  give  the  following-: 

"I  think  that  'so  much  per  hour'  proposition  in  a 
professional  charge,  is  not  near  so  satisfactory  as  a 
lump  sum;  it  has  taken  several  years  for  me  to  fully 
appreciate  that  fact.  I  have  frequently  stood  for  the 
hour  plan  when  patients  requested  a  lump  sum,  and  I 
have  gotten  the  worst  of  it,  in  as  much  as:  I  could  have 
obtained  a  larger  fee  had  I  mentioned  a  stated  sum,  the 
same  as  a  surgeon  would  do.  In  suggesting  a  fee  now, 
I  run  through  the  mouth  carefully;  size  up  the  worst  or 
bad  teeth ;  calculating  in  my  mind  the  number  at  $15.00 
per  hour,  and  then  the  others  in  same  proportion ;  and  in 
that  way  get  at  a  proposition  of  lump  sum,  always  adding 
$25.00,  $50.00  or  $100.00,  as  the  case  may  be,  in  case  I 
anticipate  the  necessity  of  a  compromise." 

My  objection  to  the  hour  plan  in  pyorrhea  work  is 
that  it  seems  to  place  our  services  on  the  wrong  basis — 
emphasizing  the  matter  of  time  rather  than  the  results 
obtained.  Also,  in  case  we  are  interrupted  by  being 
called  to  the  phone  or  to  give  a  few  minutes  time  to  some- 
one else,  our  patient  is  probably  wondering  whether  or 
not  they  are  being  charged  for  this  time. 

A  method  used  by  a  prominent  dentist  in  New  Orleans 
is  to  make  a  charge  of  $10.00  for  each  tooth,  irrespective 
of  time  required  for  a  complete  cure 

The  system  under  which  the  author  works  is  to  give 
the  patient  an  estimate  of  the  entire  cost  of  the  operation 
and  treatment  before  beginning  the  work.  This  plan 
having  proved  satisfactory  and  as  I  have  been  unable  to 
secure  minute  data  from  others,  I  will  give  it  in  detail. 


314  Peactical  Pyoerhea  Alveolaris. 

The  examination  having  been  concluded,  I  anticipate 
the  question,  "Now,  Doctor,  how  much  is  this  going  to 
cost  me?"  I  at  once  fill  out  an  estimate  sheet;  this  sheet 
gives  a  diagram  of  the  work  to  be  done  and  the  cost  of 
same.  There  is  also  a  blank  space  for  terms,  which  is 
always  filled  in.  At  the  Bottom  of  this  estimate  is 
printed  in  red,  the  following  notice: 


PRESERVE    THIS    ESTIMATE 

The  above  is  only  an  approximate  estimate  of  services 
the  exact  value  of  which  can  only  be  determined  after  the 
operations  are  completed. 

The  CHARGES  therefore  will  not  be  based  upon  this  esti- 
mate, but  entirely  upon  what  is  done.  Any  change  in  work 
named  above  or  additional  operations  will  be  charged  at 
our  regular  fee. 

We  do  not  guarantee  any  operations. 


Fig.  52. 

A  cheap  and  efficient  means  of  getting  up  this  esti- 
mate is  to  use  the  one  dollar  dental  outfit  published  by 
the  John  C.  Moore  corporation,  of  Rochester,  N.  Y.,  and 
have  a  local  printer  insert  at  the  bottom  of  page  the 
above  notice.  A  heavy  carbon  sheet  is  used  between  two 
sheets.  The  copy  is  torn  out  and  given  to  the  patient; 
the  original  is  kept  in  a  loose  leaf  binder. 

If  I  know  the  patient  to  be  able  to  pay  a  good  fee, 
to  whom  service  is  the  main  consideration,  all  that  is 
necessary  is  to  write  out  an  estimate  sheet  and  place  it 
in  an  envelope  with  the  engagement  card;  this  envelope 
is  handed  to  the  patient  on  his  departure. 

It  has  been  found  by  all  men  who  do  operative  work 
in  either  dentistry  or  general  surgery  that  a  deposit  in 
advance  is  a  most  satisfactory  basis  upon  which  to  work. 
I  have  adopted  it  as  an  absolute  rule  which  is  explained 
to  the  patients,  and,  since  J  allow  no  exceptions  to  this 


Business  Side  of  Pyorrhea  Alveolaris.  315 

rule,  no  one  raises  any  objection.  If  questioned  at  all, 
I  tell  them  that  it  is  for  their  own  protection  as  well  as 
mine;  that  I  know  they  are  as  good  as  gold,  but  that  I 
want  their  teeth  saved,  and  if  I  start  into  it  that  I  am 
going  to  do  the  very  best  I  can  towards  this  end  and  that 
I  know  if  they  have  from  $50.00  to  $100.00  paid  in 
advance  they  are  going  to  keep  coming  until  the  work  is 
done.  If  they  did  not  do  this,  the  first  day  after  their 
mouths  get  comfortable,  there  would  be  danger  of  their 
not  coming  back  for  regular  treatment.  If  they  have 
made  the  deposit,  as  I  have  said,  they  will  keep  all 
appointments  as  long  as  you  wish. 

Sometimes  a  patient,  whom  you  know  to  be  all  right, 
wishes  services,  but  at  the  time  finds  it  inconvenient  to 
make  a  cash  payment  or  to  pay  within  a  reasonable 
length  of  time.  Credits  along  this  line  used  to  be  unsatis- 
factory; at  the  time  of  treatment,  the  results  seemed  all 
that  I  could  wish,  but  such  patients  would  neglect  their 
mouths  until  Oral  Sepsis  had  again  set  in,  and  would 
declare  that  they  had  received  no  benefit  and  refuse  to 
pay.  This  difficulty  has  now  been  solved  satisfactorily 
in  my  practice  by  a  special  promissory  note.  If  they 
are  unable  to  make  a  cash  payment,  then  I  tell  them  that 
if  they  will  give  me  notes  and  pay  eight  per  cent,  for 
deferred  payments,  I  am  perfectly  willing  to  settle  the 
matter  up  in  this  way. 

This  note  is  good  for  any  kind  of  dental  operations, 
especially  pyorrhea.  If  it  is  not  met  in  due  time  and  the 
patient  for  any  reason  refuses  to  pay  same,  instead  of 
being  humiliated  by  having  to  argue  the  case  in  court, 
this  note  cuts  off  debate  in  justice  court  and  a  judgment 
is  immediately  given  to  the  dentist.  It  is  a  bad  propo- 
sition to  work  for  people  who  cannot  pay,  but  this  note 
is  the  best  solution  of  the  i^roblem  that  I  have  been  able 
to  obtain. 

If  I  were  going  to  have  any  kind  of  operation  per- 
formed, I  certainly  would  want  to  know  just  exactly  what 
it  is  going  to  cost  me,  and  I  believe  in  treating  the 


316  Peactical  Pyorrhea  Alveolaris. 

patients  with  that  fairness  which  I  would  ask  under  the 
same  circumstances. 

There  was  a  difficulty  which  used  to  present  itself  to 
me  before  I  started  to  keeping  copies  of  the  estimates. 
The  patients,  after  an  examination,  w^ere  told  about  what 
the  work  would  cost  them.  They  did  not  have  the  work 
done  at  that  time,  but  would  come  in  again,  probably, 
at  the   end   of  three   or   four  months.     After   another 


$ Atlanta,  Ga., 19 ...  . 

day  of next. 

promise  to  i^ay  Dr 

Dollars,    with   interest 

from  date,  at  eigbt  per  cent,  per  annum,  and  reasonal)le 
charges,  not  less  than  ten  per  cent,  for  Attorney's  fees,  if 
any  should  be  incun'ed  in  the  eolleetion  thereof,  and  hereby 
waiving  all  homestead  and  exemption  rights,  for  value 
received. 

^^This  note  is  given  for  professional  services  already 
rendered,  and  I  acknowledge  that  it  is  unconditional  and 
binding  and  that  no  defence  whatever  can  be  set  up  against 
its  collection. 

Witness  our  hands  and  seals 

[L-s.l 

[L.  S.] 

[L.S.] 


No 

Residence  . 


Fig.  53.    A  Good  Note  for  a  Professional  Man. 

examination  I  would  again  tell  them  what  the  charges 
would  be.  The  patient,  having  forgotten,  would  say 
that  I  had  promised  to  do  it  $20.00  or  $30.00  cheaper  at 
the  time  I  made  the  first  examination.  Now,  with  my 
present  system,  I  can  refer  to  my  files  and  can  convince 
him  immediately  of  his  mistake.  Previously,  when  other 
work  was  done  in  addition  to  the  work  estimated  on,  the 


Business  Side  of  Pyorrhea  Alveolaris.         317 

patient,  when  settling  the  bill,  could  not  be  made  to 
understand  that  more  work  had  been  done,  and  they 
would  not  think  it  right  that  any  additions  should  be 
made  to  the  estimate  as  first  named.  My  system  settles 
this  question  and  there  is  never  any  objection,  as  the  esti- 
mate suggests  and  puts  the  patients  on  notice  that  other 
work  may  be  discovered  and  will  be  charged  for. 

For  instance,  in  making  a  bridge  abutment,  if  the 
tooth  that  I  hoped  to  use  as  an  abutment  could  not  be 
saved,  then  I  would  have  to  drop  back  and  make  the 
bridge  more  extensive ;  they  often  thought  that  the  charge 
should  be  the  same. 

The  greatest  diffiuclty  that  I  have  had  is  with  the 
question,  "Now,  doctor,  do  you  guarantee  the  opera- 
tion?" I  became  so  tired  of  hearing  this  that  I  inserted 
at  the  bottom  of  the  estimate  sheet,  "We  do  not  Guaran- 
tee any  Operations."  This  immediately  settles  all  ques- 
tions, and  if  the  patient  is  not  willing  to  trust  himself 
to  my  reputation  and  skill,  he  is  at  liberty  to  go  some- 
where where  a  "cure  is  guaranteed." 

This  is  well  answered  by  Dr.  R.  Gr.  Hutchinson,  Jr., 
who  says : 

"A  cure  does  not  guarantee  immunity  and  a  true  re- 
currence in  no  way  invalidates  a  cure." 

I  find  that  the  terms  "scaling  the  teeth,"  "removing 
tarter,"  and  "treatment  of  the  gums,"  do  not  impress 
the  patients  with  the  seriousness  of  pyorrhea  treatment. 
There  is  a  fad  among  people  for  "operations,"  and  if 
the  dentist  calls  it  by  this  name,  which  is  really  the  proper 
term,  our  patients  like  it  much  better  and  are  willing  to 
pay  satisfactory  fees  for  it.  I  find  it  better  to  do  as 
much  of  the  work  on  the  first  day  of  the  engagement  as 
possible — enough  to  at  least  verify  myself  in  calling  it 
an  "operation."  In  addition  to  this  business  reason,  I 
get  better  results  as  described  in  the  chapter  on 
"Treatment." 

I  do  not  care  to  do  more  than  two  or  three  Pyorrhea 


318  Peactical  Pyoeehea  Alveolaeis. 

operations  in  one  day,  and  if  I  finish  one  half  the  work 
for  each  patient,  giving  each  two  to  three  hours,  I  feel 
that  I  have  done  enough. 

In  pyorrhea  work  the  use  of  a  proper  system  in  our 
business  dealings  with  patients  should  not  detract  from 
our  professional  dignity  and  the  returns  will  be  such 
that  we  can  have  more  vacations,  more  recreation,  and 
more  time  with  our  families. 


CHAPTEE    XXXVI. 

THE  MEDICAL  AND  SUEGICAL  ASPECT  OF 
DEAL  HYGIENE  AND.PYOEEHEA. 

VIEWS      OF      PROMINENT      MEDICAL      MEN. SUGGESTIONS      TO 

PHYSICIANS  AS  TO'  CARE  OF   THE  MOUTH  IN   SICKNESS. 

ORAL,  PREPARATION  FOR   SURGICAL  WORK. 

Dr.  C.  H.  Mayo  recently  read  a  paper  (Jan.  31,  1913) 
in  Chicago,  in  which  he  made  the  following  statement: 
''It  is  evident  that  the  next  great  step  in  medical  pro- 
gress in  line  of  preventive  medicine  should  be  made  by 
the  dentists." 

The  facts  about  oral  hygiene,  oral  sepsis  and  pyorrhea 
alveolaris,  are  of  vast  importance  to  the  physician,  as 
well  as  to  the  dentist.  In  many  cases  they  are  of  vital 
importance  and  yet  comparatively  little  has  been  written 
on  the  subject. 

It  should  be  the  aim  of  all  well  informed  dentists  to 
instruct  all  their  patients  who  are  nurses  and  physicians, 
as  to  the  importance  of  this  neglected  field  of  their  work. 
Such  instruction,  if  put  into  practice,  would  undoubtedly 
help  any  physician  not  only  to  give  comfort  to  the  sick, 
but  a  quicker  restoration  to  health. 

Every  dentist  is  familiar  with  the  great  amount  of 
decay  and  oral  sepsis  frequently  seen  in  convalescent 
patients  who,  previous  to  their  illness,  possessed  a  nor- 
mal mouth.  On  inquiry,  we  sometimes  learn  that  during 
sickness  these  mouths  received  the  usual  care  as  given  in 
hospitals. 

In  other  cases  when  a  person  becomes  sick  he  often 
neglects  the  little  attention  formerly  given  the  mouth. 
Vigorous  chewing  is  dispensed  with,  exercise  of  the 
muscles  of  mastication  ceases,  aeration  of  the  mouth 
is  lessened,  with  the  result  that  all  self-cleansing  pro- 
cesses are  diminished  and  the  saliva  becomes  thick  and 


320  Peacticajl  Pyokehea  Alveolaeis. 

ropy.  The  moutlis  of  the  sick  are  often  a  hot  bed  of 
filfth  and  disease,  as  indicated  by  the  fonl  breath,  and 
are  a  most  prolific  breeding  place  for  the  bacteria  of 
pneumonia,  diphtheria,  tuberculosis  and  other  diseases. 

Physicians  should  be  toM  by  the  dentists  that  con- 
ditions such  as  the  above  can  be  changed  for  the  better. 
The  time  will  come  when  the  physician  will  realize  the 
necessity  of  giving  directions  for  the  care  of  the  mouth 
as  a  routine  procedure  in  every  case  of  sickness.  At 
the  present  time  the  nurse  is  supposed  to  attend  to  the 
patient's  mouth,  but  most  of  them  are  woefully  ignorant 
on  the  subject  and  the  patient  suffers  thereby. 

When  a  physician  refers  a  patient  under  treatment 
to  a  dentist,  the  latter  should  not  be  content  to  limit  his 
work  to  fillings,  crowns  and  bridges,  but  should  recognize 
any  diseased  condition  of  the  gums  and  should  report  the 
findings.  This  kind  of  service  will  often  prove  of  vast 
importance  in  the  etiology,  diagnosis  and  treatment  of 
systemic  disturbances.  The  discovery  of  oral  sepsis  in 
a  patient's  mouth  is  of  far  more  importance  to  the 
patient,  the  dentist  and  the  physician  than  the  filling  of 
teeth.  This  view  of  the  matter  was  expressed  by  Dr. 
William  Hunter,  physician  and  lecturer  on  pathology,  to 
the  Charing  Cross  Hospital,  of  London,  in  his  famous 
classic  upon  the  subject  of  "Oral  Sepsis." 

"One  would  think  poorly  of  a  surgeon  or  doctor  who  declined  to 
take  the  responsibility  of  treating  a  follicular  (that  is,  a  "septic") 
tonsillitis,  but  insisted  on  handing  over  the  case  to  a  throat  specialist, 
or  who  allowed  a  patient  to  suck  continuously  a  number  of  septic  sores 
on  his  finger.  I  think  no  less  poorly  of  any  doctor  or  surgeon  who 
declines  to  make  himself  responsible  for  the  treatment  of  much  of  the 
oral  sepsis  presented  by  many  of  his  cases.  For  this  is  what  patients 
are  constantly  doing.  Wherein  consists  the  pathological  difference 
between  a  follicular  tonsillitis  and  a  foul,  septic,  suppurating  condition 
of  the  gums,  with  deposition  of  calcareous  "crusts  and  scabs"  (so- 
called  tartar)  covering  and  hiding  septic  wounds  and  ulcers,  loaded, 
as  miscrosoopic  examination  shows,  with  staphylococci  and  strepto- 
cocci'? None  whatever,  except  that  the  latter  is  exceedingly  common 
and  the  tonsillitis  is  comparatively  rare.  The  pathological  condition 
in  both  is  the  same;  namely,  sepsis.    Moreover,  it  is  a  sepsis  as  easily 


Medical  Aspect  of  Hygiene  and  Pyorrhea.      321 

recognized  and  much  of  it  as  easily  removed  in  the  case  of  the  one  as 
in  that  of  the  other,  and  the  more  urgently  requiring  to  be  removed, 
since  it  is  more  important  as  a  potential  disease  factor  than  any  other 
source  of  sepsis  in  the  body 

"The  chief  feature  of  this  iDarticuIar  oral  sepsis  is  that  the  whole  of 
it  is  swallowed  or  absorbed  into  the  lymphatics  and  blood.  Unlike  the 
sepsis  of  open  wounds  on  the  outside  of  the  body,  none  of  it  is  got  rid 
of  by  free  discharge  on  the  surface.  The  effects  of  it,  therefore,  fall 
in  the  first  place  upon  the  whole  of  the  alimentary  tract  from  the  tonsils 
downward.  These  effects  include  every  degree  and  variety  of 
tonsilitis  and  pharyngitis;  of  gastric  trouble,  from  functional  dys- 
pepsia up  to  gastritis  and  gastric  ulcer,  and  of  every  degree  and  variety 
of  enteritis  and  colitis  and  troubles  in  adjacent  parts,  e.  g.,  appendicitis. 
The  effects  fall  in  the  second  place  upon  the  glands  (adenitis) ;  on  the 
blood  (septic  anemia,  purpura,  fever,  septicemia) ;  on  the  joints  (ar- 
thritis);  on  the  kidneys  (nephritis),  and  on  the  nervous  system 

"The  following  cases  show  to  what  extent  oral  sepsis  complicates 
specific  fevers,  such  as  scarlet  fever,  typhoid,  diphtheria,  and  the  strik- 
ing benefits  to  be  got  from  its  removal. 

"In  648  cases  of  scarlet  fever  admitted  to  the  London  Fever  Hos- 
pital under  my  care  in  the  four  years  1904-7,  the  incidence  of  oral 
sepsis,  carefully  noted  by  myself,  varied  from  25  per  cent,  to  43  per 
cent.  The  effect  of  oral  antisepsis  (the  removal,  as  far  as  possible, 
immediately  on  admission,  of  every  trace  of  oral  sepsis  around  the 
patient's  teeth  and  gaims,  by  daily  swabbing  with  1-40  carbolic  acid 
solution)  throughout  the  earlier  j^art  of  the  disease  was  very  striking. 
The  chief  complications  of  the  disease  were  reduced  as  follows:  The 
incidence  of  secondary  adenitis  was  reduced  from  6  per  cent,  in  1904 
to  3.3  per  cent,  in  1906  and  1.8  in  1907;  of  cellulitis  of  the  neck  from 
5.2  per  cent,  in  1904  to  2.8  per  cent,  in  1906  and  nil  in  1907;  of  glan- 
dular suppuration  from  1.7  per  eet.  in  1904  to  0.5  in  1906  and  nil  in 
1907.  The  striking  improvement  was  due  to  the  increaseing  care  taken 
by  myself  and  by  my  residents  and  nurses  under  my  instructions.  In 
only  one  or  two  cases  out  of  the  whole  series  were  any  teeth  extracted. 

"What  are  the  general  principles  of  the  treatment  applicable  to 
medical  sepsis'?  The  first  and  most  important  is  curiosity  about  and 
careful  observation  of  the  actual  character  and  degree  of  the  septic 
foci  present  in  the  mouth  (naso-pharynx  or  elseyhere)  in  every  case 
of  medical  disease.  This  observation  cannot  be  made  by  a  cursory 
2'lanee  into  the  mouth  and  a  general  conclusion  to  the  effect  that  the 
•teeth  are  fairly  good/  or  the  mouth  'fairly  clean.'  or  that  the  mouth 
'requires  to  be  seen  to.'  If  you  look  closely  into  the  mouth  of  your 
patients  and  note  what  you  see,  you  will  observe  ever^'  degTee  and 
variety  of  septic  ulceration;  everj'  degree  of  tartar  deposit,  as  a  great 
effect  of  these  septic  inflammation  and  ulceration;  every  degree  of  sup- 


322  Pe ACTIO AL  Pyoeehea  Alveolaeis. 

purative  inflammation  of  the  gums;  every  degree  and  effect  of  septic 
periostitis  and  periodontitis,  Avith  formation  of  pockets  and  loosening 
of  teeth ;  every  degree  and  effect  of  septic  osteitis — \e.  g.,  rarefying  oste- 
itis;  eaiTsing  recession  of  the  bone  socket  of  formative  osteitis,  causing 
thickening  of  alveolus;  every  degree  and  variety  of  septic  caries  and 
necrosis  of  the  teeth,  and  as  a  result  of  all  these  conditions,  singly  or 
combined;  every  degree  and  variety  of  septic  stomatitis,  simple,  ulcer- 
ative, gangrenous.  You  will  see  all  this  in  infinitely  less  time  than  it 
takes  to  examine  a  specimen  of  the  gastric  contents,  or  of  the  feces,  or 
of  the  urine,  or  of  the  sputum;  in  far  less  time  and  vpith  far  less  labor 
than  it  will  take  you  to  examine  the  nose,  or  the  naso-pharynx  or  the 
larynx;  in  far  less  time  than  it  takes  you  to  examine  the  heart  or  the 
liver,  or,  indeed,  any  other  organ  of  the  body.  In  particular  cases  you 
will  observe  that  all  these  septic  conditions  are  jDroduced  or  intensely 
aggi'avated  by  toothplates  covering  necrosed  roots;  by  amalgam  and 
gold  fillings  which  have  become  septic;  by  porcelain  crowns  with  gold 
collars;  which,  however  good  to  begin  with,  are  never  really  aseptic, 
and  are  liable  to  become  extremely  septic.  AH  these  you  can  observe 
in  a  few  minutes  if  you  look  for  them — in  less  time  almost  than  it  takes 
to  mention  them." 

Several  other  interesting  and  anthoritative  quotations 
are  appended: 

"There  is  little  doubt  in  my  mind  that  bad  mouth-hygiene  favors 
the  development  of  pneumonia  by  paving  the  way  for  pneumococcus 
sinusitis,  which,  as  pointed  out,  frequently  antedates  a  true  pneumo- 
coccus infection.  Any  inflammation  of  the  nasal  sinuses  should  there- 
fore be  promptly  treated." — Han^ey  G.  Beck,  M.  D.  {Interstate  Med. 
Jour.) 

"Bad  teeth  are  an  enormous  factor  in  the  development  of  catarrhs. 
Many  a  chronic  catarrh  is  kept  up  for  this  reason  alone."^ — John  B. 
Huber,  M.  D.  {New  York  Med.  Jour.). 

"The  important  part  of  scarlet  fever  is  a  focus  of  infection  located 
either  in  the  nose,  in  the  mouth,  or  in  the  nasal  pharynx,  and  from 
these  sources  the  poisons  are  circulated  through  the  body.  Thus  the 
poisons  are  but  giving  expression  to  themselves  in  the  eruption  that  has 
been  held  heretofore  to  be  of  such  consequence. 

"The  importance  of  diptheria  I  am  sure  is  fully  understood,  but  the 
enlargements  of  the  glands  of  the  neck,  of  the  nose,  of  the  tonsils,  and 
of  the  pharynx  are  due  to  absorption  somewhere  in  the  nose  or  in  the 
mouth,  a  very  large  percentage  of  which  takes  place  through  cavities 
in  the  teeth  or  down  the  sides  of  unclean  teeth.  Not  only  that,  but  we 
are  constantly  confronted  with  instances  like  his,  a  child  has  been  in 
a  diphtheria  hospital  and  has  remained  there  until  it  seemed  safe  for 
the  r-hiUl  to  jjo  home.     Then  the  cliild  has  gone  home,  and  there  has 


Medical  Aspect  of  Hygiene  axd  Pyokrhea.      323 

followed  an  infection  with  diphtheria  in  that  home.  What  is  the  logical 
explanation?  The  logical  explanation  is  that  in  some  hidden  recess,, 
somewhere  in  that  child,  there  was  a  focus  of  hidden  bacteria;  and 
that  in  all  human  probability  a  large  percentage,  if  not  an  over- 
shadowing percentage,  of  those  infections  are  either  in  the  tooth 
cavities  or  somewhere  in  close  connection  with  the  tooth  cavities." — Dr. 
W.  A.  Evans,  M.  D. 

In  typhoid  fever  and  allied  conditions,  the  mouth  is 
a  veritable  hot-bed  of  the  very  infection  we  most  want 
to  control.  Just  think  of  your  patient  having  28  to  30 
square  inches  of  infected  surface  feeding  the  diseased 
intestine  and  no  attention  being  given  it.  I  have  proven 
to  my  own  satisaction  that  all  cases  of  fever  are  more 
easily  cured  and  have  fewer  complications  when  the 
mouth  is  maintained  in  a  hygienic  condition,  before  and 
during  illness. 

Frankel,  Wachselbaum,  and  Miller  agree  that  the 
most  frequent  excitant  cause  of  pneumonia  is  infection 
from  the  mouth.  Miller  says,  ''The  oral  cavity  serves 
as  a  gathering  point  for  this  infection,  which  from  time 
to  time  is  carried  into  the  lungs  with  the  air,  until  at 
last  at  some  weak  point,  or  as  the  result  of  some  inflam- 
matory action  of  the  lungs,  through  which  the  power  of 
resistance  is  impaired,  it  obtains  a  foothold  in  the  lungs. 
For  this  reason,  therefore,  and  very  m^ny  others,  the 
neglected  oral  cavity  offers  a  dangerous  cover  of  infec- 
tion, which  by  no  means  received  the  attention  it 
deserves." 

Numerous  investigators  have  pointed  at  the  tonsil  as 
a  possible  jooint  of  entry  of  rheumatoid  infection. 
Billings  reports  cases  of  multiple  arthritis  cured  by 
enucleation  of  the  tonsils ;  also,  several  cases  of  arthritis 
deformans  and  parenchymatous  nephritis  due  to  infec- 
tion of  streptococci  planted  in  pyorrhea!  pockets. 

Dr.  A.  H.  Stevenson,  in  a  letter  writes  me : 

"It  is  generally  believed  that  the  bacteria  of  the  com- 
mon infections,  viz. :  diphtheria,  pneumonia,  scarlet 
fever,   and  typhoid  invaded  the  hodj  through  the   air 


324  Practical  Pyorrhea  Alveolaris. 

passages,  but  Jonathan  Wright  and  other  investigators 
find  that  the  turbinate  bones  of  the  nose,  and  the  ciliated 
epithelium  covering  the  mucous  membrane  of  the  nose, 
act  as  selves  or  screens,  preventing  most  bacteria  from 
entering  the  throat,  bronchi,  or  lungs  by  this  route.  The 
mouth,  therefore,  must  be  the  chief  means  of  these  infec- 
tions reaching  the  lungs  or  stomach.  The  function  of 
the  stomach  may  be  impaired  by  this  bacterial  invasion. 
The  hydrochloric  acid.  Nature's  great  germicide,  is  able 
to  overcome  the  bacterial  attack  that  occurs  with  the 
normal  acquiring  of  food,  but  the  constant  ingestion  of 
pyogenic  material  from  a  septic  mouth  seriously  inter- 
feres with,  and  may  prevent  the  normal  secretion  of  the 
hydrochloric  acid.  This  may  result  in  the  subsequent 
disturbance  of  the  process  of  digestion. 

"With  a  wound  on  the  surface  of  the  body,  the  bac- 
teria and  their  toxins  are  eliminated  with  the  surface 
discharge,  but  where  there  is  a  lesion  of  the, mouth,  an 
alveola  abscess,  for  example,  the  septic  material  is  swal- 
lowed or  disposed  of  by  the  lymphatics  or  the  blood.  If 
the  resistance  of  the  tissues  is  high,  and  the  individual 
in  excellent  health,  this  daily  toxic  dose  may  be  taken 
care  of,  but  the  effect  falls  upon  the  entire  alimentary 
tract.  Dr.  E.  C.  Kirk  calls  this  the  "toxic  habit,"  and 
like  all  offensive  habits  it  becomes  apparent  to  others 
before  it  does  to  the  afilicted.  Other  results  showing  the 
results  of  oral  sepsis  could  be  continued  "ad  finen."  The 
increase  of  papers  on  this  subject  appearing  in  the  medi- 
cal journals  is  encouraging." 

In  my  experience  in  hospital  work  I  have  found  that 
the  majority  of  patients  do  not  receive  treatment  for 
mouth  conditions.  The  time-honored  method  of  using  a 
strip  of  gauze  on  the  finger  is  better  than  nothing,  but 
on  account  of  the  shape  of  the  teeth  a  considerable 
amount  of  infectious  debris  is  packed  between  the  teeth 
and  into  the  depressions  arounci  the  tongue. 

If  the  mouth  is  first  examined  in  office  practice  and 
found  to  need  attention,  the  physician  should  send  the 


Medical  Aspect  of  Hygiene  and  Pyoerhea.      325 

patient  to  that  dentist  whom  he  has  reason  to  know  will 
put  it  in  a  hygienic  condition,  and  instruct  the  patient 
in  oral  hygiene. 

If  the  patient  is  confined  to  bed,  we  know  from  experi- 
ence, that  those  who  ordinarily  brush  the  teeth  often 
neglect  this  duty. 

Whose  duty  is  it  to  brush  the  teeth  of  the  sick  patient  ? 
The  physician  should  be  able  to  demonstrate  to  some 
member  of  the  family,  or  if  a  nurse  be  in  attendance, 
instruct  her  how  to  use  the  brush  and  mouth  wash.  I 
have  never  seen  a  nurse  who  knew  how  to  brush  her 
own  teeth ;  therefore  I  give  her  implicit  instructions  as  to 
the  proper  manner  of  brushing  not  only  the  teeth,  but 
the  whole  mouth,  including  the  tongue.  I  hope  the  day 
is  not  far  distant  when  every  training  school  for  nurses 
will  incorporate  a  few  lectures  on  this  subject  in  their 
course. 

The  teeth  of  a  bed-ridden  patient,  even  if  in  normal 
condition,  should  be  washed  properly  several  times  each 
day  and  rinsed  every  few  hours  with  some  cleansing- 
solution.  The  most  serious  consequence  of  tooth  decay, 
following  sickness,  is  due  to  the  infection  between  the 
teeth.  The  use  of  guaze  will  not  remove  the  material. 
The  tooth  brush  is  a  necessity.  It  goes  between  teeth, 
it  removes  the  accumulation  as  gauze  cannot.  The  tex- 
ture of  the  brush  should  be  of  the  softest  grade  obtain- 
able. Some  good  tooth  paste  should  be  used  in  prefer- 
ence to  a  powder;  a  powder  must  be  changed  into  a  paste 
in  the  mouth  before  it  becomes  efficient ;  before  it  changes 
to  a  paste,  some  of  it  gets  lodged  between  the  teeth, 
where  it  stays ;  some  of  it  is  apt  to  be  inhaled,  irritating 
the  throat  and  lungs.  A  paste  does  the  work  quicker 
and  has  the  advantage  that  it  generally  contains  some 
antiseptic.  This  must  be  followed  by  a  mouth  wash,  and 
for  this  purpose  lime  water  or  salt  water  will  answer, 
but  a  prescription  of  chlorate  of  potash,  with  a  few  drops 
of  phenol  is  efficient  or  the  purpose  of  cleansing  and 
disinfecting. 


326  Peactical  Pyoeehea  Alveolaeis. 

Even  though  a  patient  cannot  raise  his  head,  oral 
cleanliness  must  not  be  neglected.  Here  it  is  good  prac- 
tice to  irrigate  the  teeth  and  mouth  by  turning  the  head 
to  one  side,  having  the  patient  draw  the  fluid  into  the 
mouth  through  a  long  glass  tube,  and  instructing  him  to 
close  the  lips  and  force  the  fluid  between  the  interspaces 
of  the  teeth,  flushing  the  whole  oral  cavity  and  the  throat. 
In  other  cases,  the  ordinary  long-spout  feeding-cup  can 
be  used  without  the  patient  moving  the  head.  By  closing 
the  lips  over  the  spout,  this  cleansing  liquid  can  be  drawn 
into  the  mouth  and  later  emptied  back  into  the  cup  just 
as  it  was  received.  In  other  cases,  it  is  advisable  to  use 
the  fountain  syringe  and  flush  out  the  mouth  just  as  you 
would  any  other  infectious  cavity.  Use  a  nozzle  that  will 
give  a  fine  stream  and  don't  be  afraid  to  use  plenty  of 
pressure. 

If  oral  sepsis  is  present,  in  addition  to  the  cleansing 
it  is  necessary  to  make  a  topical  application  of  some 
formulae  as  Skinner's  Disclosing  Solution,  Buckley's 
Pyorrhea  Astringent,  or  AA  Pyorrhea  Treatment 
(formulae  given  elsewhere),  or  some  similar  preparation 
containing  iodine,  Avhich  drug  alone  will  penetrate  in  the 
mouth. 

Proper  attention  to  the  mouths  of  the  sick  and  before 
operations  by  the  surgeon  will  undoubtedly  be  produc- 
tive of  comfort  to  the  patient  preventing  infections  and 
will  prove  one  of  the  greatest  aids  that  can  be  used  to 
restore  the  health  of  the  patient. 

OEAL  PREPAEATIOiSr  FOR  SURGICAL   WORK. 

If  there  is  one  place  where  the  dentist  can  be  of  great 
help  to  the  general  surgeon,  it  is  in  the  preparation  of 
the  mouth  before  the  anesthetic  is  given  for  all  opera- 
tions. The  surgeon  wears  a  mask,  and  is  all  attention 
to  every  detail,  but  often  neglects  a  great  source  of 
infection  and  danger — the  mouth.  Dentists  should  urge 
the  strengthening  of  this  chain  in  aseptic  surgery.    No 


Medical  Aspect  op  Hygiene  and  Pyorrhea.      327 

doubt  many  of  the  post-operative  pneumonias  are  due 
to  infection  from  septic  mouths  containing  pneumococci. 
In  this  regard  we  must  teach  our  physician  friends  not 
to  rely  on  rinsing  the  patient's  mouth  with  the  ordinary 
solutions  used  as  mouth  washes.  Undoubtedly,  it  would 
be  safer  for  the  patients  if  their  mouths  could  be  cleaned 
by  a  staff  hospital  dentist,  and  the  day  is  not  far  distant 
when  just  as  much  attention  will  be  given  the  mouth  in 
hospital  wards  as  is  now  accorded  examinations  of  the 
heart,  lungs  or  kidneys. 

The  above  should  serve  to  give  a  glimpse  into  the 
many  important  and  practical  relations  between  medicine 
and  dentistry.  The  solution  of  such  problems  requires 
knowledge  on  the  part  of  the  dentist  and  full  recognition 
of  the  importance  of  mouth  hygiene  on  the  part  of  the 
medical  profession. 


\  b 


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Practical  oral  hygiene. 


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